¿y tú quién eres?(2006). memory lost: a view of alzheimer...

Alzheimer’s disease

The first patient investigated was Augusta D,in 1901, at the Frankfurt Hospital (Figure 1). Thepathology revealed a correspondence between herstriking course of mental deterioration (over 5 years,beginning with delusional jealousy, she developed arapid and progressive memory loss, hallucinations,paranoia, temporal and spatial disorientation, behav-ioural disturbances and a severe loss of language), andher brain lesions1.

This case, presented by Alois Alzheimer(Figure 2) in 1906, was the first documentation of thedeterioration of the cerebral cortex to provide adescription of senile plaques, neurofibrillary bundlesand arteriosclerotic cerebral changes2.

From the end of the twentieth to the begin-ning of the present century, the first-world population

has been enjoying an apparent state of well-being. Theimportant developments in the field of health thatemerged in the last century have allowed life expectan-cy to double over the past 100 years, increasing fromonly 35 in 1900 to nearly 80 in 20003. This increase hasthe advantages that we can be with our loved oneslonger, but this has been accompanied by a spectacu-lar increase in the prevalence of pathologies typical ofthe elderly. One of the most dramatic of these isAlzheimer’s disease2.

¿Y tú quién eres? (And Who Are You?) and Alzhemier’sdisease

Technical details

Title: ¿Y tu quién eres?Country: SpainYear: 2007Director: Antonio Mercero

¿Y tú quién eres? (2006). Memory lost: a view of Alzheimer’s disease as portrayed

in the cinemaMaría Isabel Sánchez Rubio

Farmacéutica comunitaria. Salamanca. (Spain).Correspondence: María Isabel Sánchez Rubio: Paseo Florencio Marcos 21-23. 37008. Salamanca (Spain).

e-mail: [email protected]

Received 12 May 2007; modified and resubmitted 3 October 2007; accepted 10 October 2007

Summary

The cinema has always been seduced by the loss of memory and its consequences. However, the amnesia portrayed on the big screenis generally more related to head injuries than to degenerative diseases, and the health problems that are of such great importance in today’ssociety, such as Alzheimer’s disease and other dementias of degenerative origin, have tended to receive far less attention.

The gradual ageing of the general population as from the middle of the last century has meant that this pathology has now becomean almost “normal” part of our lives, with its all too tragic socio-economic and family consequences. Here, an attempt is made to reflect onthis, taking advantage of the recent work by Antonio Mercero “¿Y tú quién eres?” (And Who Are You?), which can be seen to fill a lagoon pres-ent in the Spanish cinema as regards these issues.

Outside Spain, two directors have become deeply involved with Alzheimer’s disease: Juan José Campanella, with Son of theBride/ El hijo de la Novia, and Richard Eyre, with Iris. Here we compare the work of Mercero with these latter two films from 2001 in the hopethat films addressing with the problems of old age will arouse interest in developed countries.

Keywords: Ageing, Dementia, Alzheimer’s disease, Memory, Neurodegeneration, Loss of personality, Dependence.

135© Ediciones Universidad de Salamanca

J MMMaría Isabel Sánchez Rubio J Med Mov 3 (2007): 135-152

Screenwriter: Antonio MerceroCast: Manuel Alexandre, José Luís LópezVázquez, Cristina Brondo, Álvaro De Luna,Monti Castiñeira, Amparo Moreno, ÁngelesMacua, Alejandro Zafra and Luís ÁngelPriego.Color: ColorRuntime: 90 minutesGenre: Drama. Production Companies: Buena VistaInternational Spain S.A., Irusoin S.A. andMono Films.Synopsis: The Rivero family goes on summervacation. Luis moves with his wife and twochildren to San Sebastian, his only daughterAna remaining in Madrid with Ricardo, thegrandfather. Ana is studying for a state examand decides to remain in Madrid to pursue herstudies and look after her grandfather, who isassigned by the family to a home during thesummer period. At the residence, Ricardomeets Andrés, his room mate and new friend.Together, they recall past times and discuss theevents that happened when they were young,and the spectator is regaled with scenes that areboth touching and amusing. During the sum-mer period, however, Ricardo falls increasinglyunder the grip of Alzheimer’s disease.

Antonio Mercero premiered his last work, afilm about Alzheimer’s disease on 21 September 2007,taking advantage of the fact that this was InternationalAlzheimer’s day, which coincided with the Interna-tional Cinema Festival held yearly in San Sebastian(Figure 3). To a certain extent, this work fills a gappresent in both international and Spanish cinema as

regards ageing and the debilitating onslaughtsAlzheimer’s disease.

The film focuses on the disease to such anextent that after seeing it any spectator should comeaway with at at least a glimpse of the reality and diag-nosis of the condition. This is important because itmeans that since its first showing the film has becomea point of social reference.

Globally, life expectancy has doubled inrecent years and it has been estimated that worldwidethere are some 20 million people with Alzheimer’s dis-ease4. Currently, the disease is recognised as a seriousmedical-psychiatric, neurological, epidemiological-sociological and economic problem, particularly indeveloped countries. There, dementias can be consid-ered the third most important illnesses in terms ofeconomic and social costs and are only surpassed bycardiovascular and neoplastic diseases5.

Accordingly, it is strange that a social-sanitaryproblem of such magnitude should have been accord-ed so little attention by film makers, unless –since itmainly affects the elderly- people of age have somehowbeen marginalised by the cinema. We do know, after all,that owing to its commercial interests the cinema tendsto look to the younger generations for spectators.


Figure 1: Auguste D.

Figure 2: Alois Alzheimer

María Isabel Sánchez Rubio J Med Mov 3 (2007): 135-152

Nevertheless, the repercussions of the diseasehave led some directors to address a pathology that isincreasingly making its presence felt in our advancedsocieties. This is logical since film makers oftenattempt to reflect the socio-cultural environment inwhich they live. An example is Mercero, who livedAlzheimer’s’ disease when a colleague and friendbecame afflicted; it was his friend’s demise thatspurred Mercero to tackle the issue.

It is not difficult to approach the work of thisrelevant and sensitive Basque director, despite his broadprofessional acumen. After studying law, he began hisstudies of cinematography, gaining a degree in CinemaDirection from the Escuela Oficial de Cine (Official Schoolof Cinema) in Madrid in 1962. Since its beginnings, hiswork has received many plaudits. Thus, in 1965 his shortfilm Trotin Troteras, with which he gained his diploma atthe Official School of Cinema, was awarded a prize atthe Parisian Biennale d’Art. His short film Lección de arteobtained the Concha de Oro and the Perla del Cantábrico atthe San Sebastián International Film Festival in 1962.This is not the first time that Mercero has been interest-ed in health issues: one only has to recall “Farmacia deguardia” (1991), a TV comedy series, and the muchacclaimed The 4th Floor/ Planta 4ª (2003).

This new health-oriented motion picture alsostars two of the most prolific actors of SpanishCinema: Manuel Alexandre and José Luis LópezVázquez (Figure 4).

Manuel Alexandre was born in Madrid in1917. He is one of the best secondary actors inSpanish cinema and has appeared in more than 200films. In 2003, he was awarded an honorific Goyaprize, and in 2006 he was nominated to the Goyaawards for the best actor in his role in Elsa y Fred(2995), by Marcos Carnevale.

José Luis López Vázquez was also born inMadrid, in 1922. He is an extremely versatile actorwho has appeared in about 250 films and in many the-atre productions. Mercero directed him in La cabina(1972), a television film that was awarded an Emmy in1973. In 2005, he was also awarded an honorific Goya.

In contrast to these veterans, Cristina Brondooffers a more juvenile perspective. She was born in1977 in Barcelona and plays the role of Ricardo’s(Manuel Alexandre)’s niece.

The plot of the film is very simple. A Spanishmiddle-upper class family -the Riveros- who live in anup-market area of Madrid go to San Sebastian onvacation in August. Luis (Alvaro de la Luna), his wife(Angeles Macua) and their two sons (Alejandro Zafraand Luis Angel Priego) go, but Ana (Cristina Brondo)-who is preparing for a state exam- and Ricardo (Luis’father) remain in Madrid, so that Ana, who adores hergrandfather, can be with him.

To be “freer”, and against the wishes of Ana,the family decide to put Ricardo in a luxury residence.Ricardo is not very keen about the idea of staying in


Figure 3: Spanish poster with the characters Ana and Ricardo

Figure 4: A moment in the shooting of Mercero’s film withManuel Alexandre and José Luís López Vázquez


Madrid, but finally agrees. At the residence he meetsAndrés (José Luis López Vázquez), a solitary andrather eccentric old man whom he shares a room withand who is to become a friend (Figure 5).

The losses of memory, names, appoint-ments… that had earlier begun to beset Ricardo hadpreviously been dealt with unconsciously by Ana.However, at the Residence the first signs ofAlzheimer’s begin to appear in her grandfather andAna sees how all her earlier schemes for the futurebegin to dwindle. Nevertheless, at the same time shebegins to discover the inner world of elderly peopleand the tenderness they arouse in one. The changestaking place in her grandfather have a strong impacton her and she moves from being a mere spectator ofher grandfather’s decline to becoming the central axisof his life. He is so affected by the disease that shedecides to assume full responsibility for his care andshe gives up her studies for the state exam, whichbefore had been the only thing that seemingly offeredher some kind of sense in life.

With this, we become aware of the huge emo-tional repercussions of the disease on the patient’sfamily and social environment. Mercero offers us aview of this dementia in which early treatment anddiagnosis are of such enormous importance.Although there is no cure, there are some treatmentsable to improve the symptoms, possibly even stabiliz-ing the condition. The film is in fact quite simple andcould even be considered a documentary onAlzheimer’s disease.

The cinema and memory: Post-trauma dementias

Memory and its loss have appeared since thebeginning of the cinema. In this vein we have TheGreat Dictator (1940) by Charles Chaplin, passing

through the most obsessive Hitchcock with Spellbound(1945) or Vertigo (1958), up to the more recentRegarding Henry (1991) by Mike Nichols, The Long KissGoodnight (1996) by Renny Harbin or Memento (2000)by Christofer Nolan, all based on memory loss due toshock or head trauma (table 1).

In both classic and current cinema, there arefew clear references to old age; in particular to demen-tias deriving from the ageing process. It is true thatmany films include elderly persons in the cast, but ingeneral they are not in the limelight. Few films haveaddressed degenerative dementias in depth, althoughAlzheimer’s disease and its impact on the family envi-ronment have been used in some recent movies, many


Figure 5: The central characters, José Luis López Vázquez andManuel Alexandre in the residence

Table 1: Classification of dementias*

* According to data from 6 and 7


Degenerative originAlzheimer’s diseaseDementia with diffuse Lewy bodiesFrontotemporal DementiaPick’s diseaseDementia associated with Parkinson’s diseaseHuntington’s diseaseProgressive supranuclear paralysis

Metabolic or nutritional originHypo- and hyperthyroidismHypo- and hyperparathyroidismHepatic insufficiencyRenal insufficiencyWilson’s diseaseVitamin B12 deficitFolic acid deficitVitamin B1 deficit

Cerebro-vascular originMulti-infarct dementiaBinswanger`s diseaseStrategic infarct dementia

Infectious diseases associatedAIDS dementia complexCreutzfeldt-Jakob diseaseNeurosyphylisLyme diseaseWhipple’s diseaseHerpes encephalitis

Toxic originAlcoholDrugsMetals

Neoplastic originPrimary or metastatic brain tumoursLimbic encephalitisCarcinomatous meningitis

OthersChronic subdural haematomaPost-traumatic dementiaNormotensive hydrocephaly

of them premiered in 2006, although not in Spain.

Alzheimer’s disease is a particularly destructivecondition for the patient’s family, who in general sufferfrom two losses: the disappearance of the actual per-sonality of the loved one they used to know and, withdeath, the that person: owing to the irreversible natureof the disease, the grief is felt from the very beginning.

The aim of the present article is to analyse theplight of these people in the cinema, based on Mercero’sfilm, after which we shall comment on Alzheimer’s dis-ease and its treatment in Son of the Bride and Iris.

The elderly forget; the cinematographic industrytoo: The cinema and senile dementia

The first step in viewing a film from a criticalperspective is to have an in-depth knowledge of thetopic being addressed. In this case, the plot revolvesaround a dementia. The dementias form a group ofcommon diseases that are severe, prolonged andpainful, and which have a profound impact both onthe patients themselves and on their social and familysurroundings.

Dementia is an acquired syndrome (a set ofsigns and symptoms) of organic nature that should beunderstood as a progressive decline in cognitive func-tions, among them memory. The syndrome eventuallyleads to complete incapacitation of the patient8.

In medical terms, the syndrome should fulfilthe following characteristics: there must be a normallevel of awareness; it must be acquired and must per-sist over time; it must affect different functions andmust be of sufficient intensity to have repercussionson the personal, job-related, or social functioning ofthe individual affected8.

As mentioned, degenerative dementias haveonly been gradually, although steadily, incorporatedinto the cinema. In classic films with sound, therehave been timid representations of elderly personswith dementias as secondary characters, althoughwithout much relevance to the actual films themselves.An example is the case of Gerald O´Hara (ThomasMitchel), the ageing father of Scarlett (Vivien Leigh)in Gone with the Wind (1939) by Victor Fleming. Thissituation persists in today’s cinema, as may be seen inMy Girl (1991) by Howard Zieff, where Vada’s grand-mother (Anna Chlumsky) suffers from an undeter-mined dementia.

An advance in this sense has been the por-trayal of elderly people as the main characters, such asin Driving Miss Daisy (1989), by Bruce Beresford,where the disease begins to ravage the life of DaisyWerthan (Jessica Tandy). Here, however, Alzheimer’sdisease is not the main leitmotiv of the plot and is noteven relevant to the story.

At the beginning of the twenty-first century,some scriptwriters have further explored this socio-health problem. In this vein, we have the Italian-British production Facing Windows/ La finestra di fronte(2003), by Fernan Ozpetek, and The Notebook (2004),by Nick Cassavetes, both featuring characters affectedby this pathology.

What must be emphasised is the scant atten-tion that has been paid to the differentiating character-istics of the disease and the globalisation of the differ-ent dementias, hindering its diagnosis and its under-standing from the spectators’ point of view.

Since in general the cinema does not differen-tiate and is prone to including any dementia arsing inthe elderly as Alzheimer’s disease, we shall onlyaddress this particular pathology and certain films thatdeal with it in specific terms.

A new disease, a new challenge for society: Thecinema and Alzheimer’s disease

Before the premiere of ¿Y tú quién eres? pre-cise and very specific attention was given toAlzheimer’s disease in Son of the Bride, by Juan JoséCampanella, and Iris, by Richard Eyre, both from 2001and both recounting a love story set within a drama.Accordingly, in order to be able to the analyseAlzheimer’s disease in the cinema, these films mustalso be looked at.

Son of the Bride

Technical Details

Title: Son of the BrideOriginal title: El hijo de la noviaCountry: ArgentinaYear: 2001Director: Juan José CampanellaMusic: Ángek IllarramendiScreenwriter: Juan José camanella andFernando CastetsCast: Ricardo Darín, Héctor Alterio, Norma



Aleandro, Natalia Verbeke, Eduardo Blanco,Gimena Nóbile, Claudia F ontan, DavidMasajnik, Atilio Pozzobon and Salo Pasik.Color: ColorRuntime: 123 minutesGenre: Comedy, Drama. Production Companies: JEMPSA, Patago-nik Film Group, Pol-Ka Producciones andTornasol Films S.A.Synopsis: Rafael believes that things can getbetter for him. He works in his restaurant24/7, he is divorced, and he sees his daughtervery infrequently. He has no friends and avoidscommitting to his girlfriend. Also, for manyyears he has not visited his mother, who isinterned in a geriatric hospital because she hasAlzheimer’s disease. A series of unexpectedevents lead Rafael to reappraise his life, amongthem his father’s intention to fulfil an old hopeof his mother’s: to marry her in church.Son of the Bride (Figure 6) is a drama-comedy

of a genre bordering on the philosophical that aims toarouse in the spectator a reflection about life and whatwe seek of it.

The film shows us a mature man, RafaelBelvedere (Ricardo Darín), living a crisis. He seems tobe successful, because in an Argentina continuallyfraught with problems the Italian restaurant thatRafael has inherited from his parents seems to be run-ning smoothly. However, this is not reflection on hisown life; initially he seems to be unworried by hisproblems since these are somehow always eclipsed byminor domestic crises: Rafael is unable to really con-nect with his surroundings or with his family becausehe never has the time.

Divorced, he is unable to enjoy watching hisdaughter Vicky (Gimena Nóbile) grow up; he has nofriends, with the exception of one from his childhoodwho suddenly appears out of the blue, and he prefersnot to get overly involved with his girlfriend Natalia(Natalia Verbeke). Moreover, he hasn’t visited hismother Norma (Norma Aleandro) for more than ayear; she has Alzheimer’s disease and is confined to ahome for the elderly (Figure 7).

He hits rock bottom when he has a myocar-dial infarction; he sees his poorly mother and his age-ing father (Héctor Alterio), old and running out oftime….. In this context, however, he receives helpfrom his parents, who behind all the chaos do live abrilliant love story quite different from his own situa-tion. After more than 40 years of marriage, his father–who is still deeply in love with his mother- has tocope not with only his wife’s misfortune but also withhis own solitude. Nevertheless, he does this withaplomb. To show his love for Norma, he decides thatthe time has come to marry her in a church (Figure 8),a prize he had always refused to grant her because ofhis communist convictions. Nino’s sadness, his impo-tence, can be seen as from the very first scenes when


Figure 6. Cover of the American DVD with the characters Nino,Norma and Rafael

Figure 7: Norma ill with Alzheimer’s disease together with her son


he fails to recognise the woman he visits each day atthe home for the elderly. Nevertheless, as regardsAlzheimer’s disease, the argument goes no furtherthan this. However, behind Norma’s illness, comment-ed below, we see a man’s hard reflections about lifeand what we all seek of it.

Towards the end of the plot Rafael toobecomes infused by his father’s dream to give hismother what she had always wanted (a church wed-ding) but what her illness will no longer allow her tohave. The film thus allows us to enter the life of thefamily, originally disunited, at a time when it is threat-ened by a severe illness.

It is not easy to follow Norma’s mental dete-rioration because the plot develops in such a shorttime that we are unable to fully appreciate the courseof the disease. Despite this, we are offered a hauntingview of many of the sociological aspects surroundingAlzheimer’s disease and how this affects patients’most immediate environments.

Iris

Technical details

Title: IrisCountry: UK and USAYear: 2001Director: Richard EyreMusic: James HornerScreenwriter: Richard Eyre and CharlesWood based on the books Iris: A Memoir andElegy for Iris, by John Bayley. Cast: Judi Dench, Jim Broadbent, KateWinslet, Hugh Bonneville, Penelope Wilton,Eleanor Bron, Angela Morant, SiobhanHayes, Juliet Aubrey, Joan Bakewell andNancy Carroll.Color: ColorRuntime: 91 minutes

Genre: Biography, DramaProduction Companies: BritishBroadcasting Corporation (BBC), IntermediaFilms, Mirage Enterprises and MiramaxFilms.Synopsis: During the 40 years of the pas-sionate romance between Iris Murdoch andJohn Bayley, the true nature of the concept ofmatrimony has reached its maximum signifi-cance. Together, they spent their lives fusingtheir personalities, professional activities andaspirations. Theirs was one of the literaryromances of the twentieth century, but wasalso testimony that love will triumph over thesome of the bitterest and most unexpectedevents that life can deal us.Iris (Figure 9) is a true story about love. This

“biopic” is based on two books Iris: A Memoir andElegy for Iris, by the writer John Bayley (played by JimBroadbent in the latter years, and by Hugh Bonnevilleas the young character), who was the life-long admir-er, confidant, partner, lover, and husband of IrisMurdock (played by Judi Dench in the latter years andby Kate Winslet as the young character), a well knownIrish author (Figure 10).


Figure 8: Wedding of Nino and Norma accompanied by their son

Figure 9: American poster (design by BLT & Associates) withIris as a younger and older woman


Often described as “the cleverest woman inEngland”, Iris Murdoch was a beacon figure to her gen-eration in Great Britain. From her days as a student atOxford, where she captivated all with her open, almostunrestrained, attitude to her activities as a philosopherand novelist, Iris was always way ahead of her times.

The plot takes place between two periods–the youth and the old age of the central characters.By means of startling flashbacks the director takes usto one and another moment in the lives of these writ-ers. And this is how we become aware of the radicaland irremediable change in Iris brought about byAlzheimer’s disease, a progressive decline in highercognitive functions, among them memory.

The portrayal of the earlier days shown in thefilm is excellent. Iris is a writer who lives for andthrough words, and who has a forceful but open per-sonality. She believes she has an outstanding memoryand the power of her mind is the main tool of hertrade. The plot does not actually focus on the diseasebut on the characters, both of which suffer its conse-quences and are condemned to a living death. Howawful for someone for whom words are the bread onthe table and the passion of life!

This is undoubtedly an even greater tragedythan in the case of Son of the Bride, since Iris perceivesher limitations as from the very start of her illness andthis is why she becomes frustrated and angry and refus-es to recognise the situation. The same happens withher husband, who far from assuming his limitationsdenies them until the disease is definitively installed. Hemust have detected the limitations before his wife did.

In the film there seems to be a before and an afteras regards the moment when Iris has to give a speech,and it is then that she starts to muse on the reality of hersituation (she forgets her speech), although it is not untilshe visits the doctor that her suspicions are confirmed.

We see, then, another love story in which the“healthy” partner becomes the carer of the weakerone (Figure 11). Thus, John returns to Iris the firm-ness that she herself had transmitted to him at thestart of their relationship. John, who since childhoodhad been somewhat of a “grey” figure, pales beforeIris’ sparks of geniality. He loves her but essentially hisfeeling is one of immense respect, since in her he seeseverything that he will never be or have. But then, -life’s paradoxes- Alzheimer’s disease rears its head. Atthat moment everything changes; Iris becomes a vic-tim of her own environment and John becomes theguardian of his beloved.

The film offers extraordinary insight into theevolution of the disease. It describes the illness fromthe very first moments up to its final tragic outcome:death. We are also shown a very natural depiction ofthe changes that occur in a patient’s immediate family,in this case in a single person: John.

Comparative study of the three films

There is a clear contrast between the scriptsof these last two films. In Son of the Bride the sick per-son is a secondary character and her disease is setwithin the story of the son, while in Iris the patientherself is the central character. Despite this, bothwomen are prominent in the plots of the films.

Together, both productions help us to betterunderstand Alzheimer’s disease and the repercussionsthat it has on patients’ immediate families and on soci-ety, although neither offers much as regards the diag-nostic details of the clinical picture.

Unlike these films, what clearly stands out inMercero’s work is the sheer simplicity of the story.The script writer divorces himself from romanticaspects and from the earlier or current history of the

Figure 10: Iris and John in their youth

Figure 11: John with a sick Iris



secondary characters. In this film, Alzheimer’s diseaseis not simply an illness suffered by one of the charac-ters but is the focal point of the whole film. The plotfollows a line similar to that of a medical manual: diag-nosis, prognosis, therapeutic possibilities, importanceof principal carer(s) and help from the Association ofAlzheimer’s Patients. In this sense, Mercero leavesnothing to be completed.

In all three films, Alzheimer’s disease evolves inthe same way and the descriptions of the possible sur-roundings of the characters complement one another.Two of the patients, Norma and Iris, have living spous-es and, moreover, Norma has a son who can take onthe father’s care-load. John, however, is alone in havingto cope with his partner. In the case of ¿Y tú quién eres?,we see a third possibility: that of a sick old widower -with a married son with grown-up children, with theirown orderly lives- becoming a load for the family.

Owing to their focus on the disease, all thesefilms underscore the difficulties involved in peopleovercoming their initial grief when a loved one devel-ops the illness and accepting the new situation of see-ing someone gradually lose his/her personality, even-tually becoming unable to recall even the most imme-diate events: And who are you?, asks Ricardo of Ana inthe last scene.

In this context it is of interest to analyse howpeople confront the tragedy and react according totheir own sensitivity and personalities. In the films wesee how the families must first cope with the heavyblow dealt them when they receive the diagnosis; they

know they will have to face up to an uncertain futureas regards the evolution and the duration of the ill-ness. Here we see their worry and their fear of thingsto come. The loneliness of long-distance carers is seenas a pinnacle of feelings, real or insubstantial, that leadthem to become yet further victims of the disease.

There is no answer but to face up to the diseaseand the tragic loss of a loved one in the unknown future.

Are the cases of Iris and Norma casual?:Epidemiology

The incidence of Alzheimer’s disease increas-es with age (Table 2). It is exceptional before 50, 90%of cases usually appearing after the sixth decade oflife. It affects about 5% of people older than 65 andthis figure increases to 30% in the population olderthan 85. In Spain there are some 400,000 people olderthan 60 with the disease2.

The disease is more common in women thanin men and this may be due to the fact that among theelderly more women than men survive4 or perhaps tothe decline in oestrogen levels in post-menopausalwomen2.

In Son of the Bride and Iris we see this: bothpatients are women and are older than 65. Mercero’sfilm, however, is a sharp reminder us that men are notexempt.

In Alzheimer patients there is a frequentbackground of head injuries, families with a history of

Age (years)

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90-94

>/=95

Dementia (cases/1000 person-year)

0.03

0.11

0.33

0.84

1.82

3.36

5.33

7.29

8.68

Alzheimer`s (cases/1000 person-year)

-

0,06

0,19

0,51

1,17

2,31

3,86

5,49

6,68

Table 2 : Incidence of dementias and Alzheimer’s disease

* According to data from 9



dementia, families with children with Down’s syn-drome, etc.10.

It should be noted, too, that the disease is notalways diagnosed promptly, further hindering correctanalysis of the data.

What becomes disconnected in the brains of Iris,Norma and Ricardo? Aetiology

The disease debuts in them much earlier thaneither they themselves or their immediate circle offamily and acquaintances realise (Diagram 1).Alzheimer’s disease is one of the commonest forms ofdementia and is present in about 60% of patients withthese pathologies. The disease features a series of pro-gressive and specific changes in the neurons of thecerebral cortex and of certain subcortical structuresthat prevent correct brain functioning and that finallylead to death. The process spreads gradually, affecting

a growing number of neurons. Above all, the neuronsof the cerebral cortex -responsible, among other high-er functions for thought, memory and language(Figure 12)- are affected.

The initial symptoms are not overly evident,and the families of John, Iris and Ricardo confusethem with those merely typical of old age: disorienta-tion, absentmindedness…2.

There are some psychometric tests, whichmay allow the detection of signs of deterioration inlanguage, attention or concentration2, and currentstudies are exploring the use of biological markers todetect the disease as from the very early stages.

In Son of the Bride none of this is seen, and lit-tle is seen in Iris either, but in ¿Y tú quién eres? Mercerodid see fit to include some of these tests in the diag-nosis of Ricardo’s disease.



Diagram 1: Alzheimer' s Disease Pathogenesis

John realises that something is up: Symptoms anddiagnosis

The treatment of the symptoms of the dis-ease and its diagnosis as seen in the films are hetero-geneous and, as mentioned above, the films are basedon the different developmental stages of the disease.Thus, whereas in Son of the Bride Norma’s diagnosishad been made some time before, in ¿Y tú quién eres?and Iris we actually witness the diagnoses being made.

Our first sight of Norma is when she isalready a patient, and we are not offer any insight into

the outcome; we only see the repercussions of the ill-ness. In contrast, we first see Iris as a healthy elderlylady with a profound wish to carry on working andcontributing her input to the literary world. Indeed,we see her totally immersed in the drafting of hermost recent book. Ironically, when it is published shewill no longer be able to read it. In Iris, then, since thefilm covers the story over several years we are betterable to see the devastating effects of the disease fromstart to finish, although little attention is given over todetails.

Mercero’s film offers a slightly more exhaus-tive view of all the symptoms that should alert us tothe presence of Alzheimer’s disease, with a cleardidactic purpose in mind. He does this using not onlythe character of Ricardo but also other secondarycharacters, such as Andrés and other inmates of theresidence.

The disease appears like a wolf in search ofprey. This is what initially leads Iris and John, andRicardo’s family to pay little attention to it or to treatit as “something that happens to old people”. Smallepisodes of forgetfulness, the keys, words,…. are

Figure 12: Iris’ brain scan

Loss of vocabulary at the start of the film,without social repercussions

Changes in the logical order of events.

Changes in judgement: Andrés even manages toget undressed in the dining room

Return to childhood; with games placed duringthis stage or recalling people

Changes in the order of things or words...................

Failure to recall dates, or whether it is night or day

Difficulty in handling money: trying to buy a pearlnecklace with 10€

Urinary or faecal incontinence, in the case of Andrés

Inability to distinguish between a grocer’s or ajeweller’s

Inability to recall recent data; What is Ana studying?..

Recall of childhood situations, such as songs orexperiences and inability to recall what is recent

Difficulty in performing simple tasks such as get-ting dressed

Minimisation of symptoms by patient or family.......

Difficulty in remembering the rules or the nameof a simple game: Ludo

Difficulty in reading, writing, and simple mathsoperations

Not remembering grandchildren’s names, in thecase of Andrés

Inability to remember own address

Spatial and temporal disorientation; when accom-panying Ana to the restaurant

Nervousness about answering simple questions

Disorientation; becoming lost for a whole day...........

Failure to recognise danger: when on a swing

Failure to recognise even principal carer, in thelast scene

Table 3: Signs and symptoms of Alzheimer´s disease seen in the film ¿Y tú quién eres?



merely attributed to absentmindedness or are simplyanecdotic for both families until, in the case of Iris forexample, the person forgets something really impor-tant (in her case, her whole speech, which she is inca-pable of improvising) (table 3)

In the diagnosis of Alzheimer’s disease, as inother illnesses, it is mandatory to perform an inter-view, a physical examination and request complemen-tary tests10. With the data thus obtained it is possibleto reach a diagnosis using different criteria11,12 (tables4, 5).

The Basque director invites us to witness thetype of questions asked by physicians faced with a sus-pected case of the disease. Thus, we accompanyRicardo to a consultation as if we were really there andwe see a test being applied. There is a battery of short,simple tests useful for the diagnosis of dementias, andspecifically Alzheimer’s disease. The best known arethe MMSE (Mini Mental State Examination) byFolstein et al., which is the one most used worldwide;

the MIS (Memory Impairment Screen) by Buschke;The Seven Minute Screen Neurocognitive Battery(enhanced cued recall, Benton’s temporal orientation,verbal fluency and clock drawing), the three-wordmemory test and the semantic verbal fluency test.

It would be logical to speculate that whatMercero is aiming at in ¿Y tú quién eres? is to offer asimplification of the case in order not to distract thespectator from the true causes and circumstances ofthe illness. Thus, in this first medical consultation thedoctor fails to ask about other concomitant diseases inthe central character, and this is also the case of theother people in the residence. It is as though onlyAlzheimer’s disease exists in the film.

In the film we may assume that the physicianhad previously been privy to Ricardo’s medical histo-ry, after which a battery of simple questions is givenafter his personal hygiene status has been checked.The physician follows a typical order in the diagnosis.He first engages in questions about orientation

Anamnesis

In a patient with the suspicion of a syndrome ofdementia as well as the usual data checked in anyclinical case,emphasis should be placed on thefollowing:

Family history of dementia

Family history of Down’s syndrome

History of head trauma

Educational level of patient

Aphasia

Apraxia

Agnosia

Disturbances of executive functions

Phobias

Compulsions

Obsessions

Delirium or delirious ideas

Alterations of perception

Mood alterations

Behavioural alterations

Physical exploration

A complete physical exploration should be performed:States of consciousnessHydration and nutritional statusPupilsCranial pairsPresence or absence of goitreAdenopathiesNeck murmurs and primitive reflexes

Routine complementary tests

Blood & Urine Analysis

Blood biochemical profileComplete haemogramBasic urine analysis

Lumbar puncture

Imaging tests and records of electrical activity

Cranial Computed TomographyCranial Magnetic Resonance imagingChest X-rayElectrocardiogramElectroencephalogram

Table 4: Diagnosis of dementias*

* According to data from 10



–Ricardo’s name, where he lives, what day it is- andthen moves on to addressing the patient’s capacity forreasoning, attention and calculation (counting num-bers and performing simple mathematical calcula-tions), memory (the three-word memory test). He asks

Ricardo to memorise three unrelated words. Initially,Ricardo is able to recall them, but completely changesthe order, which the physician uses to check whetheraphasia is present The doctor then changes tack toassess short-term memory and asks Ricardo to recite

Enfermedad de Alzheimer: criterios del DSM-IV

A.- Multiple cognitive deficit, manifested by:A.1.- Deterioration of short- and long-term memoryA.2.- At least one of the following signs: aphasia, apraxia, agnosia and alteration of executivefunctions

B.- These deficits imply a reduction in life quality with respect to the patient's previous level and causea significant deterioration in employment-related and/or social relationsC.- The start is gradual and and the cognitive deterioration is continuousD.- The deficits (A.1 and A.2)are not due to:

D.1.- Another CNS disturbanceD.2.- Systemic disease D.3.- Action of toxic agents

E.- The deficit does not appear exclusively during the course of a delirium (acute confusion syndrome)F.- The deficits cannot be explained in terms of other psuchiatric disturbances such as depression orschizophrenia

Alzheimer's disease: criteria of the NINCDS-ADRDA **

Criteria for possible Alzheimer's disease:

Dementia with variations at onset, during presentation or during the clinical course that are unu-sual in AD but for which there is no alternative explanationIn the presence of a secondary systemic or cerebral disturbance able to produce dementia, butnot considered to be the cause of the patient's dementiaWhen there is a gradual and progressive deficit in cognitive functions

Criteria for probable Alzheimer's disease:

Cognitive deficit demonstrated by clinical examination and documented with validated tests andscalesDeficit in two or more cognitive areas (memory, judgment)Progressive worsening of memory and other cognitive functionsAbsence of disturbances of consciousness (delirium)Onset between 40 and 90 yearsNo evidence of other cerebral or systemic diseasesThe following support a diagnosis of probable Alzheimer's disease:

Signs of progressive cerebral atrophy in serial cerebral computed tomography Presence of aplasia, apraxia, agnosiaAlteration of behavioural patterns and incapacity top perform daily tasksFamily history of ADComplementary tests: examination of normal CSFNon-specific EEG slowings or normality of the EEG

Criteria of definitive Alzheimer's disease:

Criteria of probable Alzheimer's disease accompanied by histopathologic confirmation

Table 5: Differential diagnosis of Alzheimer's disease*

* According to data from 11 and 12** National Institute of Neurologic, Communicative Disorders and Stroke - Alzheimer's Disease and Related Disorders Association



the words he should have learned previously butwhich he has now forgotten, pointing to an alterationin short-term memory. Finally, the doctor appliesquestions to observe the patient’s constructive andexecutive praxis: copy an item, which Ricardo doesnot manage to do (constructive apraxia), and the wide-ly used Clock Test: drawing a clock with all the num-bers and the hands indicating a specific time (con-structive praxis), thus gaining information about exec-utive components (constructive praxis tests with exec-

utive components). Although Ana seems to be presentcoincidentally, it should be noted that in this kind ofinterview the presence of a family member may be ofgreat use.

Mercero must have introduced this simple“screening” as an education campaign so that view-ers could be enabled to make a rapid diagnosis basedon the suspicion of symptoms in people aroundthem.

Initial phase (3-4 years)

Loss of memory of recent eventsProgressive loss of ability to perform small tasksLoss of spatial and temporal orientationChanges in personality and judgement capacityMemory, difficulties in remembering. Patients forget things: where they left something, dates ofbirthdays…Patients preserve capacity to make symbolic gestures; greetings, applause…"Gnosia" (faculty of perceiving and recognizing) may appear; i.e., patients confuse the use ofobjectsThe person affected becomes more introverted and insecure

The most outstanding aspect in this first stage is the memory lossIntermediate phases (2-3 years)

Difficulty in making small decisions, such as choice of clothes etc.Inability to recognise people close to the familyLack of interest in personal hygieneEating dificultiesBelligerence: nothing is rightLoss of social and sexual interestAnxiety and insomniaThe patients' vocabulary worsens, s/he only repeats basic words: mother, father…Almost complete loss of temporal and spatial orientationIncrease in degree of "Gnosis", inability to appreciate the danger of fire, stairs, traffic…Frequent mood changes; the person turns in on him/herself. Loss of self-criticism and language.Obscene and antisocial behaviour may develop

This is the hardest stage. The patient begins to show strong gaps in memory and this is the hardest partAdvanced (1-2 years)

Recent and evocative memory are completely lostVocabulary is reduced to a few scarce and incoherent wordsDisorientation is total and routine tasks become impossibleThere is a strong degree of apathy. Stupor and comatose states may appear

In this last stage, the patient only responds to painful and sometimes affective stimuli

DEATH

Table 6: Stages of Alzheimer's disease*

* Partial data from 14



When cognitive disturbances are doubtful,tests may play an important role in patient assessment.To perform the diagnosis, physicians and neuropsy-chologists base themselves on published guidelines andon the cut-off scores that best classify subjects as nor-mal or having cognitive alterations of different degrees.

As well as serving for classificatory purposes,the tests play an important role in the definition of theclinical picture of patients and may help in the aetio-logical diagnosis. In this setting, neuropsychologicaltests allow the profile of the altered and preservedabilities to be established and provide indicationsabout the underlying neurobiological problems13.

However, the doctor prudently does not tellAna that her grandfather has Alzheimer’s disease sinceit is not possible to unequivocally establish a diagnosiswithout complementary tests (table 5), and he onlyadmits the possibility that Ana’s grandfather might besuffering from the disease. Neither are any differentialtests performed14 (table 6).

In the case of Ricardo, the doctor starts withtests and the disease is deemed to be present when theold man is no longer able to recall daily events, such aswhere he lives. It is at this moment when he is givenan identity bracelet and when his granddaughterbecomes aware of the eventual fatal outcome.

During Iris, no excessive emphasis is placedon the time of diagnosis nor on which are tests carriedout, although we are privy to how the family doctordeals with the situation. After an interview and a phys-ical exploration, and based on his own suspicions, thedoctor sends Iris to a specialist, who carries out com-plementary tests, such as a brain scan (Figure 13) andan object recognition test, which later provide a defin-itive diagnosis. These complementary tests are notseen in ¿Y tú quién eres?

It should be noted that a final diagnosis ofAlzheimer’s disease can only be made after the deathof the patient at autopsy.

What Does Ana expect of her grandfather?Prognosis, treatment and evolution

The prognosis of the disease is fatal. It is adegenerative process and has no cure. We see this in Iris,when the specialist performing the object-recognitiontests says that it is unstoppable. Mercero also portraysthe disease in the same way when Ana is told about her

grandfather’s illness. The duration of the disease is high-ly variable: some patients die in their beds before 4 yearshave elapsed after the onset of the disease while othersmay last 15 years. The mean survival rate is 8-10 years2.

Although it is true that there is no cure forAlzheimer’s disease, as the doctor explains to Ana, byjudicious use of different therapies and drugs it is pos-sible to palliate the symptoms and, although very opti-mistically, speak of a stabilization of the disease.Accordingly, early diagnosis and sensitisation of thepopulation to the disease are very important.

The evolution over time of the disease is dif-ferent in all three films. Thus, in Iris, whose plot lastsseveral years, we see the development of the illnesssince its very beginnings (table 6) -loss of memory ofrecent events, progressive loss of skills to performsmall tasks such as routine chores, difficulty in remem-bering…. - up to the final phases of the illness, wherethe person only responds to painful stimuli and onlyoccasionally to affective prompts, death being the finaloutcome14. In Son of the Bride, we see the diseasealready present in a person and only witness the pas-sage from the middle to the advanced stage.

In the case of Ricardo, the disease is gallop-ing. We observe his decline during the course of onesummer, but the plot remains at the initial phase ofthe disease and ends when the patients is entering themiddle phase, as we see when Ricardo is unable torecognise his own granddaughter.

In any case, if in Iris we see the fatal out-come, in Son of the Bride, and in ¿Y tú, quién eres? thereis some glimmer of hope.

The power of the disease: social and economic costs

Alzheimer’s disease and the other dementiaare of enormous social transcendence because the

Figure 13: Iris undergoes a brain scan



patient’s surroundings are also affected by the illnessand because the costs involved in caring for suchpatients are very high. Neither should we forget theimpact on society at large of knowing the fatal out-come of the condition, people’s ignorance of the riskfactors, that the preventive window is very small, orthe increase in the incidence of the disease.

When a person has Alzheimer’s disease, thewhole family suffers, especially the spouse and chil-dren. They find their time limited because their duty isto look after the daily needs of the patient, whichrange from hygiene to eating, apart from the necessaryvigilance of the person involved, all of which impactthe carers psychologically2. Both the patient andhis/her surroundings lose out in terms of the qualityof life. This is seen in the films addressed here, aboveall in Iris, where the husband is the only personresponsible for looking after the patient.

Modification of the structure of householdlife is seen as from the start of the illness, above all inSon of the Bride and Iris. The patient, who in both filmsis a woman, is unable to continue running the house,working, or taking on the responsibility for for dailyhousehold chores and hence little by little the familymembers take some tasks away from them, such asadministering the household budget, cleaning… Thisis not always easy in the society in which we live, sincein previous generations there was no balanced equali-ty in the sharing of household chores, all being theresponsibility of the woman. Thus, in John’s case,when Iris becomes unable to go any further, he beginsto break down and the house becomes ever morechaotic. In Mercero’s film we do not get to see thisaspect, perhaps because the character is a man and thefamily is middle-class and can afford home help.

In more recent generations, the problem isdifferent, as we see in Son of the Bride, which shows afairly typical family of our times, destroyed by adivorce, in which both man and woman work awayfrom home, and where the children/adults/ elderlymembers have little time to spend together. Cases ofactual abandonment have been reported for suchpatients.

Mercero goes beyond both these two films,since Ricardo seems to be integrated in a perfect fam-ily in which the hustle and bustle of daily life does notseem to be a major problem because there is alwaysmoney. What is being posited by the director is theproblem of a single aspect of that family life: the vaca-

tional period. For his own good, Ricardo’s familydecide to leave him in a luxury residence for the elder-ly, it’s not very nice going on holiday with Grandpa, although itwould be better for him to see the beach, as Ana thinks. Thus,the Basque director does not pose any family imbal-ance y when the disease appears. If Ana decides tolook after her grandfather and stop studying for herstate exam it is not because of a lack of doctors butbecause of her love for him.

Ana’s question -who is to look after thepatient- always occurs in Alzheimer’s disease and Anaknows this, although her attitude is somewhat utopian.Neither the economic situation of the family norAna’s stance is very common.

In this sense, things are not always as por-trayed in the film. In real life it is precisely during thefirst stage of the illness when the main carer appears.This person is of crucial importance for the patient,has a hugely complex task and will be subject toextreme physical and mental pressure, as the doctorexplains to Ana. This person is often the spouse ofthe patient, as in the case of Son of the Bride and Iris,although it is probably better to seek help from exter-nal carers when the main role of principal carer can-not be fulfilled by the spouse (John or Nino).

The outcome of Alzheimer’s disease means that themain carer, the person most affected in the family, slowlybegins to lose his or her independence and gradually “disap-pears from sight”, dropping friends, hobbies, etc.5. We seethis in the character of John in Iris. In sum, the carereventually burns out, and his or her physical and mentalhealth deteriorates, which in turn affects the patient and theother family members5.

At that time, the need arises to take the elder-ly person to a day-care centre or a residence. From thebeginning of the film, Norma is in one such residence.We are led to understand that she has been there aftera decision was made by both her spouse and her sonwhen they realised they were unable to care for her. Incontrast, John does not send Iris into care until shehas entered a very advanced stage of the illness, andthen only following the suggestion of an outside sup-porter: the family doctor. We do not know what even-tually happens to Ricardo, but we may assume that hewill spend the rest of his days with his family.

The social transcendence of Alzheimer’s disease isclear in the many specific policies drawn up, medical specialisa-tions aimed at its treatment, and the social debate it generates5.



Regarding economic aspects, the costs associat-ed with the disease are mainly indirect. Pharmacologicaltreatments account for about 8% of the total costs,while care of the patient represents more than 77% ofthe total3. These indirect costs are mainly covered by thefamily. In all the cases analysed here, this does not seemto be a problem since the patients are from well-offbackgrounds. However, this type of pathology mayreduce a humble family’s economy to ruins. The costsare also important for the state. Currently, dementias areconsidered to be the most expensive illnesses after cardiovasculardisease or cancer. Alzheimer’s disease has particularly high costs,both direct and indirect, that affect not only the patient and his orher immediate surroundings but also society in general5.

Conclusions

The gradual inversion of the population/agepyramid in rich countries has marked a change in med-ical practice and in the incidence and prevalence ofpathologies related to ageing. Among other chronic ill-nesses related to this process are the senile dementias.

Regarding dementias, it is estimated thatabout 3,286,000 persons have some form of suchpathologies in the European Union alone, and that840,000 new cases appear each year15. Accordingly, atthe present moment dementias can be understood tobe the fourth cause of death in the elderly, althoughthey could become the leading cause half-waythrough this century.

Despite these data and the social context inwhich such pathologies occur, however, the untilnow relative indifference of the cinema industry asregards films featuring elderly people with some kindof dementia, such as Alzheimer’s disease, has beenquite patent.

¿Y tú quién eres?, Iris and Son of the Bride arethree valuable films for analysing Alzheimer’s diseasethrough the cinema. Through the big screen viewersseeing the illness are made to feel attuned to the sit-uation; they are sensitised, although the door is leftopen for them to detect the illness in their own fam-ilies or acquaintances. Mercero’s film also hints atguidelines for patients and families as regards how todeal with the situation.

Addendum

The Canadian film Away from her (2006) by theyoung director Sarah Polley also addresses Alzheimer’s

disease and has appeared in many film festivals. It is tobe screened commercially in Spain on December 212007. Again, the central character is a woman: Fiona(Julie Christie) (Figure 14).

References

1.- Martínez Lage JM. Rudimentos sobre la enfermedad de Alzheimer.[monograph on the Internet]. Navarra: Universidad de Navarra; 2004[cited 2007 Apr 13]. Available from: http://www.medicinainformacion.com/rudimentos_indice.htm 20042.- Peña-Casanova J, editor. Enfermedad de Alzheimer. Del diagnóstico ala terapia: conceptos y hechos. Barcelona: Fundación “La Caixa”; 1999.3.-Dominguez Castro A, López Alemany, JM. La enfermedad de los cos-tes indirectos Revista Española de Economía de la Salud. 2002; June:52-54. 4.- Guilló Martínez P. Comprender el Alzheimer. Profesionales. Valencia:Generalitat Valenciana, Conselleria de Sanitat; 2002.5.- Grupo Grünenthal España [homepage on the Internet]. La enfermedadde Alzheimer Repercusión social (familia, coste económico)[cited 2007Apr 13]. [about 1 p.]. Available from: http://www.grunenthal.es/cw/es_ES/html/cw_es_es_patient.jhtml;jsessionid=4KD2KTFLTTMUFLAQP2BCFEQ?CatId=cw_es_es_patient_d_01e6.- Alberca Serrano R, López-Pousa S, editors. Enfermedad de Alzheimery otras demencias. 3th ed. Madrid: Editorial Médica Panamericana; 2006. 7.- Barquero MS, Payno MA. Demencias: concepto y clasificación. In:Martínez Lage JM, Robles Bayon A, editors. Alzheimer 2001: teoría y prác-tica. Madrid: Aula Médica Ediciones; 2001. p. 1-15. 8- Gil Gregorio P, Martin Sánchez J. Demencia 173-188. In: Sociedad Españolade Geriatría y Gerontología, editor. Tratado de Geriatría para residentes.;

Figure 14: American poster with Fiona and her husband



Madrid: Sociedad Española de Geriatría y Gerontología; 2006. p. 173-188.9.- Gao S, Hendrie HC, Hall KS, Hui S. The relationship between age, sex,and the incidence of dementia and Alzheimer disease: a meta-analysis.Arch Gen Psychiatry 1998; 55(9): 809-815. 10.- hipocampo.org [homepage on the Internet]. Circunvalación delhipocampo. Diagnóstico de las demencias [updated 2007 Sep; cited 2007Sep 20]. [about 3 p.]. Available from: http://www.hipocampo.org/diag-nostico.asp11.- American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders. 4ª edicion. Washington: American PsychiatricAssociation; 1994.12.- McKhann G, Drachman D, Folstein M, Katzman R, Price D, StadlanEM. Clinical diagnosis of Alzheimer’s disease: Report of the NINCDS-ADRDA Work Group under the auspices of Department of Health andHuman Services Task Force on Alzheimer’s Disease. Neurology 1984;

34(7):939-944.13.- Peña-Casanova J, Gramunt Fombuena N, Gich Fullà J. TestNeuropsicológicos. Fundamentos para una neuropsicología clínica basadaen evidencias. Barcelona: Masson; 2004. 14.- mifarmacia.es [homepage on the Internet]. Mifarmacia. LorenzoYago MD. La enfermedad de Alzheimer (I) demencias [updated 2007 Mar24; cited 2007 Apr 13]. [about 2 p.]. Available from: http://www.mi farma-cia.es/producto.asp?Producto=../contenido/articulos/articulo_s_enfermedad_alzheimer_I15.- Junta de Castilla y León. Plan de Atención Sanitaria Geriátrica enCastilla y León 2005-2007. [monograph on the Internet] .Valladolid: Juntade Castilla y León. Consejería de Sanidad. Dirección General dePlanigicación y Ordenación; 2005. [cited 2007 Apr 13]. Available from:http://www.sanidad.jcyl.es/sanidad/cm/institucion/tkContent?pgseed=1181808719427&idContent=32495&locale=es_ES&textOnly=false



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