Well good afternoon everybody thank you so much for coming. Thank you Bill for the warm introduction and thank you to our distinguished guests from the Parliament of Moldova and of course Ambassador Ursu. As Bill said I'm Jordan Andrews I'm here with the Center for Russian Europe and it's our pleasure to have this our first inaugural Moldova event for a new effort that we are undertaking on Moldova. I'd like to offer just a few brief remarks that's at the stage for our panel discussion and then I will introduce Ambassador Ursu to give some some remarks up the top and then after that we'll have a conversation with our two distinguished guests Mihai Pupshoi who's Deputy Speaker of the Parliament of Moldova and of course Ambassador Bill Hill a global fellow at the Wilson Center and a former U.S. diplomat who twice has served as the head of the OSCE mission in Moldova. Today's discussion on Russia's malign influence in Moldova is both important and extremely timely for a number of reasons. First we all recall that one of Russia's aims when it launched its war in Ukraine was to establish a land corridor all the way across southern Ukraine and eventually to get to Transnistria in Moldova. Just a few days ago on November 30th I think most of us heard Russian Foreign Minister Sergei Lavrov who said and I quote Moldova is actually in the process of preparing to become the next victim of the hybrid war that the West has unleashed against Russia. If that's not a clear threat I don't know what is. And then just yesterday U.S. Secretary of State Anthony Blinken hosted Romanian Prime Minister Marcello Celaccio here in Washington and in his public remarks to the media before the meeting Prime Minister Celaccio urged Secretary Blinken to quote take into consideration a special relationship with the Republic of Moldova. It's the most vulnerable country the second most vulnerable country after Ukraine and the Republic of Moldova is subjected to hybrid warfare directed against the president Maya Sandu and against democratically elected government. So let's think about that for a moment. The leader of a NATO ally and a EU member state used nearly half of his public remarks with the U.S. Secretary of State to urge that the United States maintain a special relationship with Moldova to help protect it from Russian malign influence. As I said before today's discussion is both timely and important. In so many ways Moldova's story is very inspiring. Here in America we have a famous children's story called the little engine that could. It's about a small but courageous and intrepid train engine who overcomes great obstacles to climb a big mountain and reach his goals. Moldova is a lot like that little engine that could. Since its independence Moldova has faced daunting obstacles including to cite just a few examples a 30 year frozen conflict in Transnistria sparked by Russian back separatists. A Russia fueled money laundering scheme that led to the theft of one billion dollars which at the time was a significant portion of Moldova's GDP. State capture for a period of time by a single oligarch and a legacy of undue influence by other oligarchs. The near complete saturation of the information space by Russian media and propaganda institutions, near complete energy dependence on Russia and finally Russia's heavy interference in Moldova's elections and governance through financial and other support to certain Moscow friendly political parties politicians and oligarchs. But just like that little engine that could Moldova seems determined to overcome these obstacles and reach its declared destination which is full membership in the community of European democracies and free markets and never before has Moldova's compass remained so fixed on its European future. Since President Sandu was inaugurated in 2021 her government has survived a Russia backed plot to overthrow it, battled the flood of Russian disinformation and survived the public protests that resulted, has largely diversified its energy demand away from Russian sources, has accepted the highest per capita number of Ukrainian war refugees and implemented reforms that were sufficient to earn a positive recommendation for opening EU accession talks. Clearly Russia is working harder than ever to destabilize Moldova and divert it from its European trajectory. Now perhaps more than ever Moldova needs steadfast partners. In that spirit it's my pleasure to introduce Mr. Viorel Ursu, Ambassador of the Republic of Moldova to the United States to deliver remarks on Russia's malign influence and how the United States can further augment Moldova's efforts to build resilience. Ambassador Ursu is a dedicated transatlantic scholar and statement statesman he has worked and studied in the United Kingdom, Belgium, Poland, Switzerland, France, Spain and a little known university here in the United States called Harvard. With two master's degrees in EU law it's quite possible that the ambassador knows more about the EU than the EU itself. So Mr. Ambassador thank you again for being here and the microphone is yours. Thank you and thank you for the Institute of Peace for organizing this event for us. I think it's probably one of the it's not the first event on Moldova in this institution I hope not the last one. As I said when we were framing this conversation I is just because of my background as I used to work in Brussels on previous enlargement of the European Union. I'm a big believer in European Union as a peace project. I wanted to talk about Moldova's own step trajectory now to the European Union and the I hope it's going to be a historical decision just in 10 days in Brussels 15th of December when we we hope the EU leaders coming together will will agree to opening the negotiations for accession for the Republic of Moldova. I think that's the highlight of our foreign policy that's the focus of foreign policy but also is the vision that the President Sando had and that would guide the transformation modernization of Moldova for the next seven ten years and hopefully will become the member of the EU. However when I when I came to DC a year ago I had very different concerns and one of my the main two tasks that I had coming into this mission at that time that was before we were getting into the winter last year was I had two tasks one is to make sure that the US as much as the other partners in Europe continue supporting Ukraine to defend itself because it's also defending Moldova. We are the closest to the front line and at that time and even now every morning the first thing I do is opening the news the Ukrainian news watching the front line and the second task was again is seeking the help of our partners including on the EU from the US on how we can mitigate the Russian hybrid attacks that already we were seeing were intensifying especially over the last autumn. Just going back a year ago I think the Russian plan that we know much more now about that was a very simple one is using the weaponizing the energy. Moldova really had that vulnerability that we were a hundred percent dependent on Russian supply of mostly gas but also electricity which is produced from burning the Russian gas and Russian never hesitated to use that leverage you know previously to use it use it trade embargo as a way to leverage but that was really one of the most difficult to overcome just because we use the Russian gas to hit our mostly private and public buildings. So I arrived in September in October already Russia cut the gas supply by 30 percent and then first of December they cut by another 50 percent. Moldova is not a big consumer of energy still between Transnistrian region and the rest of Moldova we actually divided half and half of the consumption so when Russia cut by 50 percent we had a choice the government had a choice either to continue sharing that volume of gas or it was actually a much bolder decision I think politically that the government decided they're not going to buy anymore of Russian gas and all the supplies that continue would go only for the consumption of Transnistrian region. That meant that we really had to to find solution to find new supplies in a very short time. None of the governments in the 30 years of independence in Moldova actually ever addressed that issue of vulnerability and just in few weeks just in few weeks at that time I think Moldovan government again with the support of our partners including the US European partners as well were able to secure a new supply of gas from Europe. Russian plan was easy you you cut the gas supply you which forces Moldovan to go to buy on European market it just happened that it was seven times more expensive because everybody was struggling to find new sources of gas because we have market economy it means that the final consumers will have to pay their energy bills for heating at seven fold increase that created an inflation of 35% last year and there was genuine people struggling and there are more vulnerable population than ever that struggled even to pay the bills. As a result we saw public protests including on the street again the government some of them or most of them probably were genuine because really people were struggling and again the Russian plan was to use that protest and infiltrate some of the violent elements among the protest well trained abroad that will little filtrate and then provoke violence over overreaction from the police. There was a plan from the spring and I think that was we we found many of those details by the way on the round of US sanctions that were announced the second round was announced last June against some of the Russian agents who were involved in training some of those protest elements. I want to say without going into much details that Russian plan failed I think on the again what really helped us is that many of our partners primary European but also the US supported us from those difficult moments. I keep repeating that the the friends they need are friends indeed and we really saw who our real friends are including from the US it unprecedented when the when the administration but the Congress adopted a substantial support for Moldova about 300 million just to secure our energy to provide support for our energy security. Some of the money including the European helped us to compensate some of the costs the rising costs for the most vulnerable consumers but also help us to look into future and reshape our gas grid and also electricity grid and to prepare us to be much more independent in our future energy production and supply. Russian failing on on on this scenario of course doesn't give up and we see continuous efforts to try to change and to influence both politics but also the population in Moldova and there are many ramifications of that most recently we had elections local elections we saw a lot of illegal money funding going to various new political projects in Moldova energy remains again another weapon that Russia tries to to continue to use even in the elections we saw some promises of cheap gas supply coming from a very untransparent offshore companies most probably Russian sources to very specific region that would vote for Russian candidates and then most recently again trade embargo Russia just last week introduced again trade export embargo Moldovan fruits and vegetables which many of our farmers still rely on and of course this information and misinformation it's still very much of it is controlled by some of the Russian sources which of course is a much difficult to overcome especially for democracies including Moldova where you really have to balance on freedom of opinion expression freedom of speech and curtailing some of those disinformation sources that primary focuses on propagating hate especially towards Ukraine also I think this new reality is being also reflected in the updated national defense strategy which was sent to the which was announced the president sandoor a month ago and is now in the in the in the parliament and I hope my my colleague here deputy speaker of the parliament me high pop sure I can go into more details so I really wanted to share those which I I hope at least positive for me in one year seeing how the situation was a year ago and this winter for instance we are entering the winter it's much confident much much better prepared probably the best prepared into the winter because again with the support from the US Europeans we were actually able to buy gas when it's cheaper in the summer cheaper than what would have be the price from gas from if they actually continued the the the contract and we for the first time we actually have enough gas in our reserves to go for the winter so even the fluctuation of prices wouldn't affect so that required a really bold leadership of course it was very risky but as I said what doesn't kill you make you stronger and we always managed to get through some of those challenges and provocation by the Russia to to become stronger and I think this year we are definitely proved again with the support of our partners in the US Europeans that we can overcome some of those challenges thank you so ambassador thank you very much for those remarks the the explanation of the energy steps that Moldova has taken is is really hopeful and obviously energy was one of the main vectors of Russian malign influence so wow that's a lot of progress in one year but thank you for framing I think it's perfect for this discussion that we'll that we'll be having so now I'd like to introduce a little bit or two distinguished guests and then have a little bit of a discussion and I will do my utmost to save some time at the end for audience questions. Mihai Popchoi is deputy speaker of the Moldovan parliament and vice president and international secretary of the ruling action and solidarity party of Moldova as an expert in Moldova's political dynamics as well as regional security developments he previously conducted research with a number of us think tanks and institutions and worked for the NATO center in Moldova so thank you very much mr. speaker for taking time to be with us today ambassador bill hill in the far chair is a global fellow at the Woodrow Wilson Center for scholars he's a retired foreign service officer and ambassador hill was twice appointed as head of the osc mission to Moldova where as I understand it according to his biography he was quote charged with negotiation of a political settlement to the transnistria conflict and facilitation of the withdrawal of Russian forces arms and ammunition from Moldova wow that's an that's a very ambitious mandate and bill I think I speak for all of us here and possibly for the entire country of Moldova when I say just how disappointed we are that you were unable to resolve the transnistria conflict in two tries and escort the Russians out of Moldova but I understand you're still working with Moldova and Moldovans and so there's still hope yet and but thank you also for being here and sharing this time with us ambassador hill of course remains one of the us the foremost us experts on Moldova both either inside or outside the government and of course esteemed former foreign service colleague and a good friend to both Moldova and this institute so thanks thanks again bill and now I'll open with one question for each of our panel members to get the conversation started and then we'll see where the conversation goes from there and speaker pop sure if I could begin with you and again welcome to us ip thank you for for being here during your visit my question is this we're all waiting hopefully and dare I say expectantly for the european council decision next week on accession talks for Moldova and ukraine in fact as I was mentioning backstage I'm even wearing my eu tie as a good luck charm hope hoping that the decision goes well um speaker what are some of the specific steps that Moldova is currently taking we already talked about energy but there are some other vectors for russian malign influence not least of which democratic interference disinformation corruption and even transnistria um perhaps speak to us a little bit about what what other things Moldova is doing to try to make itself more resilient in the face of russia's malign influence thank you and I really appreciate the opportunity of presenting you some of the successes that Moldova has achieved in the past two years and of course some of the challenges still remain when it comes to russia's malign influence as it was mentioned already as we speak Moldova is debating the new national security strategy which will hopefully be approved this week well it should be approved since we have an absolute majority in parliament uh it is a belated document in the sense that if you ask a proper security expert in Moldova and even anyone who follows the difficulties that Moldova has had in the past decades they would tell you which entity is the main national security threat to Moldova yet to this day this has not been reflected in Moldova's national strategic documents it is only this week we will be voting in a national security strategy of Moldova spelling out that russia is the main national security threat of Moldova and not only spelling it out but also making actions taking actions in order to build resilience in our institutions with that particular threat in mind unfortunately for far too long Moldovan politicians have not only avoided this truth but they've been actually actively engaging in promoting russia's malign influence in Moldova including and not limited to the propaganda which some of them politicians benefited directly from the broadcasting rights of russian tv stations in Moldova and of course the political parties that the russians have been sponsoring to do their bidding now that we've established clearly albeit a bit late that russia is a main national security threat we will have to invest more resources again something that we should have been doing all this 40 years 30 years but ironically it was also the the russians that have been inoculating this idea into the Moldovan public that security is a neutrality is a guarantee of security which is of course cannot be further from the truth no neutrality clause of any country has precluded an aggressor from taking advantage of the vulnerability of that country but the fact that the russians have promoted this idea that neutrality is a guarantee of security now it's very difficult to have this discussion about alternatives to Moldova security but we are opening this discussion and we are again spelling out in Moldova's national security document for the first time that we need to explore other avenues of ensuring Moldova's security not just limiting ourselves to neutrality and increasing our cooperation with NATO as again you don't have to have a phd in in security studies to realize that for a country like Moldova in the region that Moldova finds itself in such an alliance as NATO is the only guarantee of proper security but it will take time for us to to debate this in the public domain and to democratically engage with our citizens so that we break through this spell of Russian propaganda through this wall that has been built for 30 years that neutrality is a guarantee of security and to add insult to injury it is the the sheer fact that it was only Russia that was violating Moldova's neutrality for these 30 years maintaining unwanted military presence in Moldova and actually committing itself to withdrawing those military presence from under the 1990 99 OC summit in Istanbul and failing to do so up to to this day so Moldova is is clear in its in its stance now and will continue to support Ukraine because we realize that the suffering and the sacrifice of Ukraine it's not only for Ukraine's sake it also to keep us safe as well so we'll continue to provide our infrastructure and our our support and our openness of our homes to to our Ukrainian friends and neighbors and we are very thankful to the international community for helping Ukraine but also helping us and in this very difficult time when it comes to to Russia exploiting our vulnerability they they are now moving towards exploiting the democratic process against our democratic future they're trying to hijack our democratic elections in in their favor and that's why we had to take drastic measures to defend our democracy by the constitutional court declaring unconstitutional that party of shore the oligarch that is a fugitive from Moldovan justice and we'll continue to defend Moldovan democracy it doesn't give me any pleasure to be announcing that we had to to implement measures that preclude certain political parties from participating in the democratic process but then when these political parties have been actively engaging in corrupting our citizens and we've seen that time and time again including in the gaguzia election in the autonomous region just lately and even though i was sort of bragging at the beginning that we have 63 percent of seats in parliament and we have an absolute majority in parliament there is no way how i can compete or any other political force in Moldova can compete against cash i can tell Moldovan citizens that we are implementing robust reforms in combating corruption in building rule of law in strengthening Moldova security in embracing and and in implementing and defending human rights in Moldova but if somebody is offering that same citizen a hundred euros or a hundred dollars in cash unfortunately nine times out of ten and i might be optimistic here the people will take the money and that's why we had to take measures and thankfully our international partners and our citizens frankly understand that difficult times require difficult measures to be taken and we are thankful that the international community has supported us throughout this time to build our resilience in the energy sphere in our defense sector and i must commend our our minister of defense who have been so instrumental in doubling the Moldova's defense budget without necessarily using public resources just because of the openness and the generosity of our international partners he managed to double the budget but this year we also increasing increasing the defense budget because we need to to to play to invest our fair share as well and in this again national security strategy we are committed to increasing Moldova's budget in the upcoming years to one percent of GDP not quite there with the two percent of the NATO standard but then again the majority of NATO members are not quite fulfilling that standard for us one percent is a big is a big target because we've always had about point three percent point four percent so we are making serious steps in defending and and and increasing the resilience of our institutions and when it comes to the transition region of Moldova when it now that hopefully we will start negotiations with the EU this should be the biggest breakthrough the biggest opportunity also for the resolution of the conflict of the peaceful resolution of the conflict because the business elites in the transition region much like the rest of Moldova they see the benefits of being part of such a big market such a peaceful rule of law driven market as a european union and i'm very hopeful that the start of the negotiations will create this impetus that will kick start the process in a way that we unfortunately haven't seen for 30 years speak about sure could we return maybe to the media environment i know there have been legislative projects and steps taken to try to limit Russia's dominance a traditional dominance in Moldovan media and given the size of the media market there the model was not sufficient to generate a lot of new content from Moldova and so you were Moldova was was depending on Russia and elsewhere for for for free content essentially what steps has the parliament taken where where is that headed in in Moldova as i mentioned we've been in this very very odd situation when some of Moldova's politicians who pretended to be pro-european were rebroadcasting Russian propaganda in Moldova which was cannibalizing the advertisement market because you can imagine Russian federal TV channel with what a hundred million or more euros for entertainment budget being put in the same legal footing to compete on the national Moldovan market with the Moldovan TV channel which barely has a total budget of a million euros a year if at all that was an unlevel playing field and with the start of the Russian aggression in Ukraine and frankly even before that we were concerned but we were in opposition but when the Russian aggression started it took us a year and i'm not at all happy that it took us so long but we had to weigh all the pros and cons we're concerned about what our citizens are going to react while international partners are going to say because after all we are the biggest promoters of freedom of media and freedom of speech in Moldova and we didn't take this decision lightly but then when December came and it was a year into the Russian aggression in Ukraine the European Union shut down Russian propaganda in the EU Russia today and we figured if it's good for you to take these measures and it's about time that we take care of it as well so we shut down Russian federal TV channels in Moldova again very belated decision but we addressed that but it will take years for us to actually remedy the damage that has been done in these 30 years and also we need to invest more in quality content in Russian language in Moldova so that citizens who are Russian speakers have something to watch be it entertainment or news in the language that they understand proper quality content and we also have now a newly created institution a strategic communication unit that we modeled after our friends from the Baltics that will oversee the national media environment and social media to find and analyze and pinpoint where the narratives come from and where the attacks are coming to us and that the other proper institutions the national regulator and the audiovisual and the intelligence service so they can take action in due time and we've been proactive in defending our informational security a bit late but as they say better late than never and we're taking our information security a lot more serious and again we'll continue to invest in our security and information security and we need to provide those alternatives to our citizens and also in this national security strategy that's also an important element in building resilience in our institutions because we understand that when you live in Russian propaganda bubble when your citizens are left one-on-one with with with Russian propaganda that is inviting and creating the increasing the fertility of the ground for the Russians to exploit so we will address that thankfully but we'll take time as I mentioned to remedy the damage that is done and I have to thank American taxpayers and then USAID for supporting independent media in Moldova because without the support of the United States and European Union it would not be possible for for those few independent media in Moldova to be able now to compete and to win against the Russian elements that they are trying to to promote in Moldova. Thank you very much that's that's really useful interesting perspective on how far things have come but speaking speaking of how far things have come Ambassador Hill if I if I could turn to you help us with some perspective on on how far Moldova has come in building its resilience against Russian malign influence what in your view remains to be done I'm thinking particularly in the Transnistria space and how much things have changed there over the years and what can the US and other friends of Moldova do to to help Moldova as it as it builds up its resilience well thanks very much first of all for having me and I guess I'll start up with following the introduction you were the mea culpa indeed I didn't get it solved but I do you know if there's one thing did you accomplish anything in two terms as head of the OSCE mission when I arrived in Moldova in June of 1999 there were over 500 Russian tanks APCs and mobile artillery plus tons and tons thousands of trucks and other pieces of Russian military equipment in the Transnistria region and 40,000 metric tons that's metric tons not pounds of ammunition at Kolbasna all of the tanks APCs mobile artillery other military equipment and half of the ammunition are gone as Russian forces crossed the Dnipro through Kherson towards Mikhailov and the Ukrainians successfully resisted them imagine what might have happened had there been a second front from out of Transnistria into a Yesa oblast with that military equipment so it was 20 years later but it turns out actually there was something to what we did there we we for various other circumstances we didn't get done everything we wished to but this is emblematic of some of the changes four quick points and as what's the same and what's changed two things are really the same and Moldova is when the Soviet Union fell apart or when I was first there actually I was first there as detailed to the Department of Defense and OSD policy and visiting Moldova in the mid 90s as a DOD official the Russians still look at Moldova you know just Moldova Ukraine Belarus is their western perfect it's basically they admit it recognize them as independent but the Russians certainly I get this out of personal dealings they still consider that it's theirs it's it's and it's not just Soviet it's part of the Russian Empire Bessarabia first was annexed by Russia in 1812 and this this is an underlying attitude well independence okay as long as you vote the same way we do everywhere then you're perfectly independent to vote exactly as we tell you to either the the other thing in Moldova is that Moldova is a for a small country it is linguistically and ethnically complex with a number of minorities and in particular Deputy Speaker Pupshoi has referred to it that the extent of Russian language is broader than one might surmise if you just looked at the statistics for the last names of population whether you know ethnic Romanian Russian Ukrainian or whatever and it's it's it's been an ongoing problem because culturally the Russian speaking population for various reasons has been prone to getting influence from Russia you know and whether you know if it's some things if it's reading Pushkin or or watching the opera Boris Goodenoff it seems relatively harmless if it's other things as a Russian media environment and I lived in it it was a Russian media environment because of the strength of the Russian media as opposed to the Romanian language and that's been very hard to deal and it remains a problem which means that the the the avenue for Russian influence has been very stubborn and persistent what's changed well you know the Russians used to when I first came there the Russians used to penetrate get a lot of influence into Moldova through Transnistrian region 2014-2015 that changed as I one of my senior Moldovan friends said now Ukraine's on our side and the Russians don't get into Moldova through Ukraine and Transnistria and that's very important because it has led to a waning not an absence but a waning of the of the power of Russian influence through Transnistria the other thing over 30 years Russia or Transnistria has changed in that overtly Russian staffed and run institutions have receded a bit and local businesses and institutions that that are run by locals have become more influential and more determinative in how Transnistria looks at things it's not absolute the Russians still have people there they have influence there the FSB in particular is very well represented my estimation probably bigger danger right now than the uniform Russian military who were there but the Russians can't get to Moldova as much through Transnistria so they've been trying to get to them through energy I was working with the government when you know Kazat came down in 2021 made a you know it was really a nice offer to the Moldovans with a poison pill inside and when Yakishinau recognized the failings of the offer the Russians immediately resorted to energy present pressure and the other thing they have done is is the electoral influence you know I you know I can't do everything but you know they have come you know especially through the shore party just over you know trying to buy the electorate and the risk to Moldova here despite the progress that the current government has made taking advantage of opportunity moving really on the way I hope the hope the vote of the council will be good you know this month and I presume it will be because the signs are there but you know Moldova clearly has done very well in moving towards eventual EU membership and the candidacy process you know has its difficulties every kind of it's been through it knows that but I I see success here but politically the government is still vulnerable to Russian political you know Russian interference in the political process because of this portion of the electorate through poverty and through linguistic orientation still remains vulnerable to the media propaganda the political propaganda and the simply buying of votes and I don't have time to go into what they're doing but it really it's it's something where thankfully it looks like militarily thanks to what the Ukrainians have done the Russians militarily are not going to get to Moldova and thankfully Moldova and Ukraine the current government seemed very much on the same page supportive of each other proceeding together towards the EU it's in Moldova the Russians get there through an oligarch in refuge in Israel and this is the big danger now is that local elections just occurred the results were mixed inconclusive I would say pass didn't do as well as you wanted to it was not by no means a failure but it's clear that the political battles for the presidency in 2024 and the battle the parliamentary elections which must must come by mid 2025 are going to be you know require serious effort and I think my friend Mr. Popchoy has outlined the real problem is you know how do you deal with the political force that has strength in the country but does not accept the rules of the game does not accept basic democratic procedures principles in other words is is not going to play fair and is dedicated to restoring Russian influence and floating what seems to be a desire of a clear majority of the Moldovan population so that is what I see you know things have changed in the sense of how the Russians have been coming at Moldova and seeking to keep Moldova in their orbit but the basic problem really hasn't changed that much in in 30 years it's more acute now because the war next door but it it's not a dissimilar problem to what I first witnessed when I came there in the mid 1990s thank you very much bill we put a lot out there on the table we've talked about most of the major vectors of Russia's malign influence in Moldova I think this would be a great opportunity now we have a very Moldova supportive Moldova friendly audience we've got some real expertise in the audience so I would like to open the floor to audience members who would like to ask questions and we have a microphone back here Ellie I think we have someone up here oh yeah and there's here to cut okay thank you very much my name is Anna Seneva I'm here in a private capacity but I work for a religious organization and I'm a member of a religious minority that is currently under heavy crackdown and Russia like pretty much any religious minority I'm from Russia I'm a US citizen right now and I'm wondering I have a question for a mr. deputy speaker in your policies and in your plan in joining hopefully joining the EU what is your strategy on supporting civil society and particularly freedom of religion or belief because Russian government and the Russian Orthodox Church infamously infamously have been four decades bringing forward a strategy both inside the country and in the neighboring countries to divide and conquer to stigmatize minorities of any kind and with the with the objective of getting governments in other countries to crack down on any elements that aren't welcome in Russia either so just to crack down on any civil society journalists NGOs religious minorities and I think they've been very successful in a lot of countries so just wondering if you're you know aware of the strategy and what your plan is well I must say that I'm incredibly incredibly proud of our record when it comes to supporting and promoting minorities in Moldova all minorities we have in our faction in parliament ethnic minorities linguistic minorities religious minorities and we are proud of the diversity that we represent within our faction in parliament because in our effort to transform Moldova we need to make use of every single citizen's capacity to participate I am very proud to say that in the Republic of Moldova we have one of the best records in women empowerment we have 40 percent of women in in parliament thanks to the double quarter that we implemented and I have a suspicion that in the next election our list is going to be 50 50 and in this respect we try to be what Russia is not we're trying to be as European as we can be and we're trying to be as welcoming and accommodating to all our citizens no matter the differences that we have that has been a big credo and is a big credo of our present myosando and a big expectation of our citizens so we are incredibly open and we are incredibly supportive of civil society this year we're going to implement a funding to support also media in Moldova civil society and they are a reliable partner for us in our European aspirations so we are as open as we can be of course we can do better and we will do better thank you for that question let's go up here ambassador thank you I'm Pamela Smith and I was U.S. ambassador to Moldova some 20 years ago but it seems like yesterday in some ways it's wonderful to see so many people so interested in this wonderful country I was fascinated deputy speaker when you talked about the evolving attitude tornado in Moldova when I was there neutrality seemed like perhaps a way to keep Russia at bay maybe that's what Russians wanted Moldovans to think but anyway could you speak more please about the kind of relationship you foresee or wish to acquire with NATO thanks you're totally right in the 1994 constitution the neutrality clause was put there in the hope which is not a good strategy but nonetheless in the hope of shaming Russia in withdrawing its troops munitions from the republic of Moldova the clause of neutrality was put there in 1994 it is still there and the Russian troops are also there so that didn't help that was the primary idea behind neutrality clause there wasn't much of an evolution in our perception neutrality in the 30 years and when I was working for the NATO center in kishno 2008 2009 2010 I was hoping that there could be a change and went in 2014 after the annexation of Crimea there was an uptick in NATO support in Moldova it went from about traditional 25% it went about 35% and then in a couple of years it went back down to the traditional 25% and it was a shame because it was clear what the main threat in the region is and it was also clear what the main avenue to mitigate the threat is but because of Russian propaganda and quite frankly because of the political elites in Moldova were not proactive enough in advocating for NATO and discussing the alternatives to ensuring Moldova security we are stuck with the reality that we find ourselves in we now try to mitigate some of the damage and we are much more open in discussing the alternatives to neutrality but it needs to be a democratic process we need to we cannot impose a change of Moldova's security stance we need to persuade our voters that a democratic change and our closer relations with NATO are the proper way forward and we are committed to doing just that thank you another one back here thank you my name is Matthew Murray and I wanted to ask the deputy speaker if he could talk about what you've done to defend the banking sector the finance sector to create resiliency within you know the financial world to resist Russian money laundering to resist the use of conflict loans which were both of which were at the root of the prior financial crises in the country so where do you feel Moldova stands on building up the resiliency of the finance sector including through the central bank and and the role of the parliament in that thank you we have come a very long way from the banking fraud when 12 percent of GDP were siphoned off and Moldovan taxpayers ended up footing that bill and will continue to pay for that hole in the budget for years to come but the banking sector has become a lot more resilient and I'm reminded every day when I go to the bank about that resilience because as a politician as a politically exposed person have to provide all kinds of paperwork to the bank every time for like 100 euros or 500 euros or whatnot any transaction it's but I'm reminded of why that is in place and I am of course frustrated by the paperwork but I am also very unhappy that that was not in place when the fraud actually happened because if everything was in place and all those mechanisms were in place then Moldovan taxpayers would not be left hanging with with that incredible burden for years to come to be paid but now the banking sector and the central bank and all the private banks have implemented robust measures that the threat of the banking sector being used against the Republic of Moldova is a lot lower and the banking sector now we are looking at in our effort to dual oligarchization it's a tough word to reduce the influence of oligarchs in Moldova the banking sector has an important role to play and given that all of our oligarchs and our fugitives and are outside the country the fact that the banking sector has all those mechanisms in place to keep them at bay and not allow them to use the banking sector to increase their malign influence or the Russian influence I'm confident that the measures that have been put in place will keep those nefarious influences at bay unfortunately what is a lot more difficult to mitigate is the cash the money mules that the Russians have been using now in elections we have the 10k limit which is like everywhere else and we cannot sort of address that because then we would hurt a lot of law-abiding citizens but they were exploiting and using money mules to carry cash into the country to buy those votes in elections so we are trying to mitigate that at the exchange office it's a mixed result so far but that's part of the bigger societal effort and the bigger reform that we're implementing in the justice sector and the anti-corruption center so that we can mitigate some of those avenues but in terms of the banking sector I'm confident knock on wood that will never be in a position that we were 10 years ago where we ended up being known as you know the country that that allowed itself to to 12% of GDP being stolen that's that's not a tagline that that I want to see for my country I have enough questions for the next four hours but I'm kind I'm mindful of the time we have just a few minutes left and this side of the room has been hogging all the questions I want to give this side of the room a chance if there are questions sir you want L is coming with the microphone good afternoon everyone I'm lieutenant general poparado in a national army of republic of Moldova officer currently I'm a student at the national defense university here in washington dc doing my master degree in strategic studies and one of my paper actually is a russian influence in Moldova so I will take this advantage to ask again mr hill a question regarding Moldova and russian influence so in your opinion what is a russian center of gravity in in Moldova and what are the critical vulnerabilities that can we target in order to make this center of gravity fall apart thank you well thank you and I instructed a couple of your predecessors when I was on the faculty of the national war college the center yeah I think you can deduce from what I said the center of gravity of russian influence right now is is the Moldovan public is what they they need to do is to manipulate enough of the electorate so as to be able to take control or participate in control of one or more important institutions in Moldova and Moldova clearly that's going to be the parliament the they were successful in electing a boshkan in gagausia but fortunately that that that influence can be limited and has already had a reaction locally as well as on the national level but there is a real risk in the electorate because historically the electorate has gone back and forth between center right center left governments and it's been shown that some of the the center left governments have been overtly or moderately pro-russian or subject to russian influence and I think that's what the what Moscow is trying to do now both covertly and overtly uh and the Moldova you know the government is engaged in a number of measures already that that mr. Popshoi has has mentioned there are others that that will have to be done you know identifying overt operators the the money mules many many other things of trying to sneak people into Moldova and what they do do overtly through media through disinformation and in simply buying votes the shore party has special stores where people go and get them buy stuff at a discount and other stuff as long as they vote the correct way in the orche region one of the regions and you know try to expand that in any case that's that the politics ironically is now really because Moldova has transnistria has transformed a bit Moldova has dealt relatively successfully with the energy problem and it's now central is the political challenge that is posed by this interference that's my perception and that I think over the next year or so is going to be the real the most important fight for those who wish to keep Moldova on its present course thank you so I think we can do one more quick question and then I'm going to give deputy speaker pop joy the opportunity to give us a last word I think there was one more on this side no let's go back over here thank you thank you so much yes yeah that's a matter from Georgia currently the fletcher scope along diplomacy uh phd candidate um I have a problem about question about the topic of disinformation in Moldova you uh deputy speaker you address some aspects of it could you let us know what are some of the critical outstanding areas as it relates to russian disinformation in Moldova where experts and western allies could help more and expedite the process hopefully well as I mentioned the institution that we are building now headed by our former minister of interior under Ivanko the strategic communication unit we hope that with the help of our international partners we'll be able to provide enough capacity to this institution to be indeed the bulwark against the the russian influence online and offline and so that the other institutions can take actions but also we need to be more proactive at the societal level we need to educate the citizens so that they can understand what are the the threats towards Moldova security because now having lived in the russian propaganda bubble sometimes you find the situations that are really heartbreaking and painful to to to take when you have a citizen who is denying the fact and the horror of the russian aggression in ukraine while in the neighboring house you have ukraine refugees living so when you have this sort of reality and this sort of of pernicious russian propaganda it will take a long time for us to be able to break through but that's where we need to to invest a lot more that's where I mentioned that we are now channeling our resources and hopefully we'll be successful in creating in the public broadcaster channel that is in russian language that will provide quality content that we try to win over some of those citizens who have been living in this russian propaganda bubble but there is a lot more to be done also in the political realm that the russians have been using political parties to advocate their agenda but this is an effort that we need to to mitigate together as a society and i'm confident that with the support of our international partners and on the way to our european accession we'll be able to address the challenge yeah thank you for that question i'm fantastic haircut by the way so the deputy speaker's comments actually are a good reminder that you know moldova is not alone in dealing with with russian malign influence dare i say it even here in the united states we have at times had our challenges in detecting and resisting russia's malign influence and so one of the the takeaways i hope from this session is that there's even more that we can be doing with other countries that are victims of russia's malign influence to share experiences share best practices share techniques share technologies basically anything that can help our societies um resist the the messaging resist the influence resist the corruption resist all of the ways in which russia tries to penetrate and to gain influence in in our in our societies and so um with that any last words mr deputy speaker i just want to mention that after 30 years of dealing with this luggage without a handle the community of independent states which isn't much of a community and not a lot of independence being allowed to these members we are exiting now and we've been voting with by the dozens all kinds of multilateral agreements that we had in the cis and moldova is taking ownership of its independence of its sovereignty and we are thankful for our international partners for supporting us in the challenging times moldova wants to be something that uh it was denied he wants to be a proper european state to return to european family of nations so that in moldova people can live in peace comfortably pray to whoever they want to pray love whoever they want to love vote for whoever they want to vote and we are committed to providing all those uh uh rights and freedoms to our citizens and thanks to the generous support of our partners in the european union and in the transatlantic community i'm confident that we can mitigate the challenges that our societies are facing and we'll continue to stand with ukraine and we count of all of our international partners in doing just that thank you i hope you'll help me in thanking deputy speaker pub shoy and ambassador hill for this session thank you all


Thank you very much for inviting me to do grand rounds of truly an honor. Today's topic is going to be on screening for dementia. We'll talk, give an overview of dementia with focus on Alzheimer's and some rules of thumb for differential diagnosis of dementia. Next we'll talk about Alzheimer's versus mild cognitive impairment. We'll ask why should we screen for dementia, and finally talk about what we can screen with. Dementia is a growing problem, particularly as the population ages, and you can see the graph here that the number of cases has projected to double every 20 years or so. It's a common and growing problem. The definition of dementia is a decline in cognitive function, sufficient to interfere with daily activities or occupational function. Dementia is more of a syndrome than a diagnosis. There are many different causes of dementia. That's one of the most frequent questions I get asked by patients is, what's the difference between Alzheimer's and dementia? And well, dementia is the general term. There are many different causes. Alzheimer's is one of the most common. So there are primary dementias, Alzheimer's, Lewy body dementia, and temporal dementia, normal pressure hydrocephalus. There can be dementias associated with other neurological diseases, Parkinson's patients develop dementia as do honeytons and MS patients. We have far enough along can also become demented. There's a number of medical illnesses that can predispose or cause dementia. Toxins and meds are an important cause. There's so called pseudo dementia or severe patients with severe depression. It's important to distinguish. There's vascular dementia, which can be either due to multiple small strokes or few large strokes. And probably in the like 70s and 80s, certainly the 80s, the most common cause of dementia is actually a mixed Alzheimer's vascular dementia. It's important to be aware that, of course, neoplasms can cause a dementia, neoblastomas and so forth. There's a number of infectious ideologies, HIV, Acropocytesfeld, Neurocephalus. In the case of that recently, it's pretty rare these days. And nutrition, chronic alcohol, something to consider there. So the standard dementia workup, you're all familiar with, CBC, ChemPanel, B12, Thyroid. Maybe check for inflammatory markers. EG is kind of optional, usually unless we really think the patient's having seizures. A few screening infectious disease labs, MRI of the brain to exclude certain adversarial causes. Biomarkers, we'll talk about that more in a minute. I think you're going to become critically important. That said, though, the estimate of reversible dementias is very small. But the most important workup is a careful review of medications, alcohol, and substance abuse history. In my experience, I've been amazed sometimes. You know, talking with a guy who seems like a very standing citizen in straight sugar, re-asking how much they drink.  And if they can stop drinking, that might, you know, I can play a definite role in reversing their memory problems. It's very important to get feedback from an informant, usually the wife or a son or daughter, on their perspective of the patient's functioning. You should inquire about educational occupational history so you can get some idea about the patient's background. And sleep history, some patients with memory complaints can be related to obstructive sleep apnea, which is a reversible cause. Plus, there's increasing evidence that sleep apnea is actually a risk factor for Alzheimer's disease. There's something called the lymphatic system which clears amyloid is active during sleep, and that's impaired in people that aren't getting a good night's sleep. So quickly, here's some rules of thumb that differential diagnosis of common dementia symptoms. So for Alzheimer's, you have a typical story of gradually progressive history of memory loss. There's fairly minimal vascular disease on MRIs. On the other hand, if you have a stepwise history, multiple vascular risk factor, and the MRI shows strokes, then you think of vascular dementia. If patient is, you know, again, up in their 80s or so, and they have strokes on MRI, but they're kind of a gradually progressive history that probably you're looking at a mixed Alzheimer's and vascular dementia. On the other hand, if the patient is relatively younger and has prominent behavioral problems, then they can behavioral vary in front of temporal dementia. If they have a problem with gait disturbance and a trigger of megalomy, you'll think NPH, well, I'm sure I do sephalus. And if they have concurrent Parkinsonism, visual hallucinations, and marked day-to-day fluctuations, that's the homework for diffuse Lewy body dementia. Okay, so a little bit about basics of Alzheimer's pathogenesis. So it all starts here with the amyloid precursor protein. Which has a carboxyterminus in the cytoplasm and the amyloid terminus in the movement. And the key action here is taking place in the transmembrane portion, primarily right near the transmembrane portion. APP is a very evolutionarily conserved protein, and scientists have been working for some time on trying to define exactly what it does. It's involved in embryogenesis and synaptogenesis, functions in the peripheral nervous system. So that was quite a bit. Now it's processed by a variety of enzymes. And so here's the amino acid sequence of the protein used to transmembrane it right outside of it. And there's different cleavage sites for different enzymes. And this is very important because there's a non-amyloidogenic pathway for cleavaginit, amyloidogenic pathway. So for the non-amyloidogenic pathway, first the APP gets cleaved by alpha secretase and then gamma secretase. And the fragments it produces are harmless. On the other hand, if the protein is first cleaved by beta secretase and then gamma secretase, that's when you get release of this abeta-42 or abeta-40 fragment that is gone together and form the pathologic hallmark of Alzheimer's, which is the plaque. The other pathologic hallmark tends to develop later in Alzheimer's, the neurofibrillary tangle, which is intracellular, whereas the plaque is extracellular. And the NFT is related to tau pathology. So Alzheimer's progression, in the first stage, you just have the abeta-plac pathology. But you have biomarkers like the positive anulary PET scan or low cerebral spinal fluid abeta-42 levels. The reason why it's low is because it gets sequestered in the extracellular flax and doesn't circulate in a spinal fluid. That's a little bit counterintuitive. Tau, on the other hand, in the second stage, CSF tau becomes elevated. And here's where you start to get things like brain atrophy on an MRI scan. And you can also see abnormalities of metabolism on FTG PET. In the third stage, you have biomarkers plus subtle cognitive decline. So you start to see problems. Very first clinical symptoms are only in the later stages, actually, as it were, that then lead to more over mild cognitive impairment in Alzheimer's disease. So there's the amyloid hypothesis of Alzheimer's, which has helped sway for decades now. And some of the evidence for that includes that genetic mutations in the APP protein, or also Precinal 1 and 2, which are involved in amyloid processing, cause a familiar Alzheimer's disease. Trisomy 21, Down syndrome, APP is on Trisomy 21, is on the chromosome of 21. So you have an extra dose of it, and there's also evidence that the abeta pathology can occur decades before you get any clinical manifestations. There may also be interactions between amyloid formation and subsequent tau formation. So the graph here shows that the, again, the first thing that happens is amyloid accumulation. That's followed by synaptic dysfunction in the tau media, the coronal injury. Then you start getting brain structural damage that's visible on high skins and form of atrophy. And then finally, you start getting cognitive aspect, a little bit of cognitive decline, and then it becomes more visibly visible. So biomarkers. So there's the floor beta peer or amyloid scan, is a light end that binds specifically to amyloid clack. So here we have people at different stages of amyloid pathology. If you have mild cognitive impairment and a positive amyloid scan, your chances of progressing in Alzheimer's disease are seven fold higher than if you have a negative amyloid scan. One problem with it is that you're going to have false positives and cognitively normal elderly. But on the other hand, it could be that these people are actually on their way to Alzheimer's. Or perhaps there's something about their biology that's resistant to amyloid. Great question. No. Two big problems with amyloid scans, they're usually not covered by insurance and they're very expensive. There are other Alzheimer's biomarkers, hippocampal atrophy. There's a program called NeuroQuant that can define hippocampal volume. So if you have a low volume on a NeuroQuant analysis that is consistent with Alzheimer's. CSF amyloid tau, we mentioned earlier, the ApoE4 gene. So ApoE4 is the major kind of risk factor, a genetic risk factor in the population for Alzheimer's. But you can't, you know, you can have before and not have Alzheimer's. And conversely, you can have only E3 and still have Alzheimer's. But if you have an E4 allele and you have some memory symptoms, the odds are that does increase the chances significantly that cause of your memory problems really helps Alzheimer's. Other AD biomarkers, we mentioned temporal parietal hypermetabolism on FTG PET scans. Blood tests, we're really looking forward to those and there are some under development, particularly phosphorylated tau proteins or the beta 42 ratios. They're not quite ready yet for climb time. They're not reimbursable, but my feeling as the next year or two, we're going to have, that will be very helpful. So you've probably all heard in the news about adicandamab, drug made by Biogen. Will it be a game changer? So adicandamab is a monoclonal antibody that binds and clears and we plaque. It was zero doubt that it does that. And it's very clear that it's effective in getting rid of amyloid plaque. The controversy is over the clinical effect. There's a long saga of what happened. So the initial trials were halted by Biogen after futility analysis. But then after they reanalyzed that, they found that patients with mild cognitive impairment, mild ulcers did show some benefit and more evidence is accumulated, for example, for the extension data after two years, the patients who had a decrease in p tau 181, this is a blood biomarker, had better outcomes on clinical measures, more trials are planned. Really has their own drug, dynamamab, which looks somewhat similarly in their trials are in progress and have shown some positive results. Danziger is really expensive. It started out at 56 K a year and Biogen cut it to 28. And the risk of something called area, amyloid-related imaging abnormalities, these are like inflammatory changes that occur and are visible on MRI. Many times it's asymptomatic, but it can cause confusion and headaches. You have to opt to drug if that occurs. Although they do have it as the later on when it calms down, you can restart it. But the risk of area means that you have to do routine MRI monitoring as well as MRI scans, if you suspect that there's clinical effects of an area going on. Now, CMS recently ruled that in order to be reimbursed, in order for an academy to be reimbursed, you have to be involved in a clinical trial that meets their criteria. And right now, that's not going on. I think the trials are in the process of getting formulated. But on a practical level at the moment, given that most Alzheimer's patients have Medicare insurance, without participation in a clinical trial, you're not going to get reimbursed. Okay, next topic is Alzheimer's versus mild cognitive impairment. So again, the natural history of Alzheimer's start out normal, then you start to decline a bit, get the MCI stage, mild Alzheimer's and severe Alzheimer's. So mild cognitive impairment, or if you have a positive biomarkery, you can call it prodromal Alzheimer's disease. So kind of a fuzzy boundary between normal aging and dementia. On the one hand, the cutoff to a normal person means that your memory or other cognitive domains are not what is technically defined as one and a half standard deviations below the mean on some cognitive test. And then to distinguish from dementia, there's no significant occupational or functional impairment. This is a bit of a fuzzy boundary. One person's MCI can be another person's dementia. Take two people who have identical cognitive functions. Okay, and one of them is a high powered corporate attorney. Well, it may not take all that much blossom memory for him not to be able to function in his job. So he has to take disability retirement. So he's in the Alzheimer's range. On the other hand, the other guy with the same degree of cognitive impairment. Okay, so he doesn't remember the football scores. We can be forced. No big deal. He's MCI. The older Alzheimer's drugs like colonist recent numbers have not been shown to work in MCI. But stay tuned out where to say about that. So distinguishing normal from mild cognitive impairment is sometimes an art. There's kind of two clinical situations. One is both the worried well. These are older people that notice some senior moments and they're worried. Oh, God, am I getting out of this disease? But they don't really have it. And the second situation are patients that don't have any complaints themselves, but you do a screening cognitive test and they have trouble with it. So using, you know, various cognitive tests, the mini mental and I have my own test, which I'll introduce you to later, can help with the assessment.  Now, they're going to be in the dementia range, not MCI. How are particularly people with intermediate sources scores? You have to factor in the effect of drugs, medical illnesses, stressors, educational occupational background. So sometimes it's hard to tell and you may just have to follow the patient all the time. Some helpful tools in determining crossover from MCI to dementia. They're caregiver assessment tools, which I'll show you in a sec and asking the caregiver this question, would you feel safe leaving the patient home alone for a week? They say no, that's intuitively that they feel that they don't think the patient is cognitively well enough to be able to manage on their own. And the degree of deficits on the mental status is how bad are they in? Mini mental or broken, but it's a continuum rather than a bright line. So I'll tell you about the functional activities question here. This is again, caregiver filling it out. So zero to three scale and 10 items covering handling finances, shopping alone, reading skill, keeping track of events, remembering appointments, traveling out of the neighborhood, and so forth. So this is what it looks like. And by the way, if any of you are interested in getting your copies of these questionnaires or screening testimonials, describing later, feel free to email me and I can send them to you. So again, the caregiver fills out the zero to three scale these various activities. You have a score of ranging from zero and no problem three completely unable to perform. Another helpful item for your history is the 88 outside of his disease, eight informant questionnaire. Here, the caregiver fills out, yes or no, if there's been a change in the eight items, such as repeating questions, storage statements for the correct month or year and so forth. So there's some overlap of the FAQ, but there's also some like earlier things that it has that are sensitive. Here's what it looks like. The caregiver just checks yes or no for these eight different items. And you have a score of greater than two as a sensitivity of 74% and specificity of 85% or a dementia diagnosis. So this can help kind of round out your history here, these different problems that the patient may have. Another questionnaire that I like to use is the neuropsychiatric inventory short form. This is a two page form that gets at no behavioral symptoms. These tend to become more prominent mainly in the moderate dementia stages. But the caregiver rates for each of these things like illusions, hallucinations, hesitation and so forth, depression, anxiety. Whether it's mild, moderate, or severe, and how much distress it causes the caregiver. Anywhere from zero does it bother them at all. The five is very distressing. Carrier or stress, that's actually a major problem in out-term patients that patients may be sort of blissfully unaware that they have problems, but caregiver certainly isn't. And here's the second page of the MPIA. Short form. So what happens to MCI patients? So the conversion rate, Alzheimer's disease varies among studies. Usually, most of them, I get it around 10 to 20% per year. Again, if you have a positive biomarker that indicates you're more likely to go. But on the other hand, some MCI patients can remain stable for many years. A small percentage could even revert back to normal and then progress again later. The factors that predict or prevent conversion are underactive investigation, clinical things. We'll talk about it in a minute, like exercise and so on, as well as biomarkers. American Academy of Neurology recommends MCI patients to be monitored at intervals for evidence and cognitive decline. Okay, why should we screen for dementia? It's the next topic. So Alzheimer's disease is often misdiagnosed. They're often diagnosed with some other cause of dementia or depression, maybe, or it's just normal aging, stroke, etc. So only 28% of patients that had Alzheimer's were initially diagnosed. And dementia is, in patients over 65 and primary care practices, is estimated to be around 10% or so. But of these, it's estimated that around half are not actually diagnosed. So who do they fool? Well, they fool themselves often. There's a phenomenon called anosognosia where patients are not aware that they have a problem. So if you ask an older person, hey, have you noticed any memory problems as you're getting older? And they say no, haven't. Well, that may be true. And they, in fact, are normal, or it can actually be a manifestation of the disease. They do have memory problems, but they don't have the insight to recognize that that's the case. So they can fool themselves, they can fool the family as well, give some reasons why that's the case in a minute, and they can fool you. So how do they get away with it? Well, social skills are often preserved early on in Alzheimer's. So patient with really mild symptoms talking to them in your clinical encounter, you really may not pick up that, you know, this person has a problem. And also Alzheimer's, you know, insidious onset. So excuses can be made for gradual loss of function, such as it's just age. I mentioned earlier that, you know, retirees may not be stressed intellectually. So nobody notices their subtle cognitive decline. And from the family's perspective, they may dismiss it and say grandma is fine, you know, she still recognizes the family after all. But again, of course, it's short term memory that's affected early on in dementia. Or denial, his memory can't be all that bad. He can remember all about his high school graduation. And on our part, you may not ask routinely about their complaints, may not test for it to the gloss over it or blame it on pressure. Okay, so why should we screen for dementia diagnosis in an earlier stage allows for better planning, such as financial planning, giving power of attorney and so forth. Driving risk, we'll talk about in a sec, can be a postoperative delirium risk factor and medication compliance over this in a minute. And as diagnosis of early dementia is often missed, unless we use screen tools. If you do a screening test and it's negative, that can be a positive thing because it establishes a baseline. In my practice, it's been very helpful if I've seen the patient a few years before for some other reason. And I did a screening test and they did okay.  I think then, you know, repeating the test, you can compare it directly. And if it's negative, you can provide the patient reassurance that, you know, right now, everything seems to be okay. Keep an eye on it. Sometimes doctors will just prescribe the nepozyl, the patient has a complaint. And that their memory is going and not, you know, establish a form of diagnosis. But there is a problem. Earlier treatment, even with the older drugs, maybe more beneficial than later treatment. This is somewhat of a controversial statement, but there's some Scandinavian studies recently that indicate that patients that are started on colonoscopy inhibitors early on tend to have less like nursing home placement and mortality than patients that are started later. And another reason is it's now part of that here requirements for patients that you do some kind of screening. So postoperative delirium. So I asked her over at Hopkins did a review of hip fracture patients included that preoperative cognitive impairment is the thing that's most consistently associated with postoperative delirium. And the American Geriatric Society has clinical guidelines for delirium prevention and treatment. But I don't think anybody's really done a study yet of implementing routine dementia screening for surgeons who are planning on doing hip fracture repair and then taking action to prevent delirium and do the patients actually have a lower script delirium. So that'd be a really good study to do, but certainly if the patient has screens, you know, that they have significant cognitive impairment. That should alert you that they do get some kind of elective surgery and see if they could have problems. Drives the risk of crashes increases without service. Patients definitely if they're in moderate to security measures should not drive at all. mild patients. I usually recommend they get a driving safety evaluation, the OT or the motor vehicle association. There are certain programs like Sinai and Good Samaritan that have occupational therapy driving emails. If they flunk, then their license gets pulled. And that can be a major, you know, kind of problem with these patients that they're not happy about the positive independence from driving. There's better than getting into or, you know, crash. There's old ladies trying to order cheeseburger and large fries from the mailbox here. Spectators are commenting that testing seniors for driving isn't a bad idea. Medication compliance. So here's a quote in clinical practice awareness of non adherence as a result of cognitive impairment is relatively low. Most important step is really detection of cognitive impairment. So you have a patient with cognitive impairment, you don't realize it. You may be upping their medications. Not because they're not working, but because the patients are not taking them consistently. So patients that have some client, they may need additional oversight from family. Early versus later intervention. So I mentioned Alzheimer's drugs that we have. Presently they're widely available. Can offer symptomatic benefit at least. And then there's a variety of lifestyle things like exercise and cognition. The more you exercise, the less likely it is that you become the meta. There's a lot of evidence for that. Staying cognitively active, socially active dietary factors. A heart healthy diet diets that are rich in flavonoids may have protective function. So there have been some clinical trials where take patients with MCI. And you have them, you know, under start an exercise routine. You know, intervene dietarily, etc. And some of them have had a positive result. Although others have not so that's still kind of getting fleshed out. Okay, finally, we come to what to screen with so. There's a variety of dementia screening tests. Sure, we know. We'll talk about the mental mocha. Something called memory impairment screen clock draw many cod. Hopkins verbal learning test slums test and finally my own test. Q and E are quick and easy. So here's a good old MMSC. You guys are all familiar with it. I'm sure. I point out and I mentioned this again later that the things that are most sensitive on this test. For dementia, the three item recall and date. That shows up early on. On the other hand, things like naming a pen or watch. You don't lose that through your pretty far gone. Those items are sensitive to both mild water or severe dementia. So it's useful for following patients throughout the course and there is evidence that.  These activities of daily living abilities. With the more severe many mouths being associated with. More easier ADLs like being able to clear the table versus traveling along. Problems with the minima. Well, it's not really sensitive for why other intelligent patients. On the other one hand, the other is not specific for patients with low education or IQ. There's some scoring issues with it like some many metals. You have the serial sevens versus the world backwards, which would be used. I practice in Baltimore city. So. There's no such thing as asking what county or it's a trick question. It takes a little while through ministry is now copyrighted. So if you're going to. Publish anything with it, you're supposed to get permission from the. People that on the copyright, although I've yet to be busted by the many mental state police. On the other hand, it's still useful for staging and communication. Everybody understands, you know. Roughly with a mini mental state score of 17 means versus 26. Now the mocha is more difficult for the many men. You should keep in mind it was a norm that smart Canadians when your college education. And cut scores are much lower in other populations. And in particular in the demographic of Baltimore city where you have. Patients that have a lot of demographic challenges with education and so forth. Um. That's using the cut score of 27 or 26 just. Is too non specific. I find it particularly useful though for is for people, you know, really smart over people that have mild deficits. It does take 10 to 15 minutes to administer. And so here's the test. It has a five item recall separated by a number of other things, including the serial sevens, which is education sensitive. The memory impairments free. So this is a four item. semantically encoded items that patients asked to remember to show what that means in a sec. So they read a lot for words from different categories and they're given a cue and asked to match the word. And then you ask them, okay, what were the words I showed you on each paper two minutes ago. And scoring is two points for each. One they recall spontaneously one point with a cue zero if they don't get it even with the cues which is zero to eight scale less than four is dementia five to six is borderline. Seven days is normal. So I use for example. United Nations platter chests and emails and patient reads them and then you say okay, which one of those is a dish platter. Email organization went game chess. So the semantic encoding helps with our specificity. So the MIS and the Einstein aging study compared to a straightforward three item we call did have higher sensitivity and specificity for detecting dementia. Talk to our test. So ask the patient draw a clock. So that's a 10 past 11. I'm a various scoring systems been proposed. In practice, I really don't think people follow these different scoring system, particularly. It's mainly gestalt if it's normal or it's not very sensitive to really mild patients. It is part of the mini college. We'll talk about it in a second is worth three points on the mocha. So the mini college is a three item recall with a clock draw in between. So I was just going to call the six items screener, which is the day of the week date and I'm sorry day of the week month and year with a three item. You know, that's in between learning and remembering the three items. The minicog is basically pass fail. But it is judged to be one of the best fast screens. Although it does rely on this three on recall. And because it's mainly past failure can't really use it to follow progress and patient. Next step is the Hopkins verbal learning test, which I really like. This is a test. It was developed by Jason Brant over at Hopkins years ago. And it's a list of 12 words. And there's four for them in three different categories. This instance, it's animals, jewels. And shelters. And so you read the list. And the patient repeats back as many as they can to go through three times. And so the initial recall scores the summer family to remember on each of the trials. And then there's a discrimination index. Which is a patient just says, yes, you know, if the items are on the list. On that list, go through 24 words here. 12, which of course are on the list. And 12, which are not six of them being the same category like Ruby is a jewel. Cat is an animal. And you take the number of correct versus and subtract the number incorrect to get the discrimination index and you add that to the recall score.  Total memory score and under 24 is just a live outs ever since I bore a line. And this is under 28 is 28 and under a very handy, very sensitive is to do a 10 minute recall. So you come back and surprise the patient. Like after doing their rest of their exam or something 10 minutes later say, okay, what are the words on that screening on that long word list that we did a little while ago. And they should be able normal as seven or up. And six or below indicates there's a problem. This tenant recall is pretty sensitive to memory problems. The slums that St. Louis University, the state was developed for veterans but subsequently validated other populations. Test orientation. We call with both a five item list here. And also there's a story that's told. I'll ask several questions about the story. It's been shown to be better than the mini mental at detecting MCI like the mini metals of 30 points scale 27 that was considered wrong. The last few minutes I'll tell you about my Q&E test. It's working easy takes 95 seconds and so one of the major impediments to busy primary care docs doing dementia screening test is time. This is one of the fastest, you know, tasks you can do. I there's actually two parts to it. We're only going to be talking about the Q&E part. Rational. So what's the single most sensitive test for outsiders? It's the late recall after initial coding. A good test for outsiders or semantic fluency animals and many can use that actually as a standalone test. But it is a little bit educationally sensitive despite so orientation to date. I mentioned the MMSC. And so for the most bang for your buck simply insert of a good test in between encoding and recall. So there are four components and coding type of orientation, verbal or semantic fluency and I could recall. The encoding part I use paired associates like red ball, white horse, blue key and patient has to repeat them. Now, if they mess up the encoding scores based on how many times you have to repeat the audience before they say them correctly twice, not necessarily consequently. So if I have to repeat once, I don't take off any points for that. I'll point out the higher scores are worse on the Q&E. So it's kind of like negative points is how you can think of it. So zero is if I have to repeat it once, they don't take off that they may not have paid attention. They didn't hear, etc. But if I have to repeat again, that's one point. If they still don't get it, I have to repeat it again. That's two. And they still get it after that. I'll just go one by one and score three points. So you can get a sense sometimes just from this. Anybody who scores it two or three. On the encoding aspect is going to have problems down the line. Okay, then you ask the patient, okay, what's today's date? Allow, I allow one day plus or minus on the date. Two if you have the wrong month three off if you have one year. So I consider more of a cognitive sin not to know the month date and even more so not to know the year. So I read it accordingly. Unlike the meaning not all or mocha where it's just one point off for each of them. So you can lose up to six points on that. Okay, then it's animals in a minute. And I also take off the repetition now when I have a patient this I'll like note down, you know, how many, you know, what time it is that we started exactly the second hand. So, and write him down as patient goes along. So zero points is 14 or more one point 10 to 13 animals to seven to nine, etc. Let's take off a point. If they have more than one uncorrected repetition. And Tuesday have more than three of uncorrected repetition.  Rather than saying, you know, dog, cat, horse, cow, pig, I sent dog, I sent cat. So I don't think off of that. But if they offer up a old animal, not recognized, they said before. That's a repetition. And else other patients tend to do them. So then finally a cute recall one of the three things I gave you remember. You don't get further cues like saying they have colors. So it's a zero to six zero if they get them all right six if they are never any. Once in a while they may mix them up in which case it's a happy free child that was on the list but incorrectly paired. And so some of the items in each section is total Q&E score. So normal is zero to two threes kind of borderline. So three of the Q&E scoring zero to three for encoding up to six points for temporal orientation. A number of points you can lose on category fluency and recall. So zero to two is normal threes kind of borderline over three is cognitive impairment. I did a study some years back with a guy, Dr. Alan Trubin, a neurologist who runs a mammary clinic in Spokane. And he had his nurse test patients with a Q&E and something called the Washington adaptation of the Attenberg's Climbing and Evaluation. So the ACE test was in England and it's a hundred point test and he adapted it for Washington state. For example, by asking who's the governor of Washington state rather than who's the prime minister of England. And you can extract out of that the meaning of the state, the mini cog, the six item screener, which I mentioned briefly earlier in a clock. Dr. Trubin did not know the Q&E results. He just had the ACE test available. And he made the diagnosis of normal MCI or Alzheimer's disease or other dementia or clinical programs. So how did it work out? So we stratified patients by their mini mental state scores. And there's very mild patients we call those are people with normal mini mental states of 27 to 30. The Q&E of score four and above picked up like 70% and was statistically better than the other tests.  Here's one or two patients who had mild that service with mini mentals of 21 to 26. And overall, you know, it was like 80 plus percent picking up mini mentals patients who were diagnosed with dementia with mini mentals of 21 to 30. And I don't know if the clock draw here, not do all that great compared to the other tests. So summary slide here of different mental status tests, time less than two minutes is educationally sensitive. Is there an adequate point spread to follow the patients over time? And does it require the patients to draw it right? That could be handicapped if you're patient has some motor impairment or you're testing in a hospital setting. So the mini mental, for example, takes longer than two minutes. It is educationally sensitive. But it can, you can use to follow the patient over time. My test is less than two minutes. The animals may have a little bit of educational sense that they, but it shouldn't be for the other things. And it does have an adequate point spread to follow patients over time. But once patients hit bottom or severe, you can't use it. It's really just following patients over the like mild course. So in summary, cognitive impairment, dementia is often detected in the doctor's office. Patient and family may be unaware as well. You can improve your detection by using some of these screening tests. And detection is important social consequences for the family as well as the patient. And interventions for treating cognitive impairment are available. Hopefully drugs like Atacanamide or its successors proven to be effective in the earliest stages becomes even more imperative that you identify these patients early in the hour. Okay. Thanks very much for your attention. I'll point out my email address here again if you're interested in trying some of these tests after yourself and what forms are just so many. Thank you.


Let us start. So last session, we have actually started heat transfer, and we have completed the conduction mode of heat transfer. So now we are getting into the other modes of heat transfer. And why we are studying the different kinds of modes of heat transfer separately, because every mode of heat transfer follows a different set of rules. So that is why we are studying the heat transfer of different types separately. All right, so all of you please write down the next mode of heat transfer is convection. OK, so convection heat transfer, I will start convection heat transfer with some example. You might have, for example, have you ever taken a hot utensil and then you poured cold water on it? I think many of you have tried that. So if you take hot utensil like this, then you have option to either put cold water in it like this and cold water just go away. And then newer cold water will come, get in touch with this hotter surface, and then will go away. This is one way you can cool this. Another way that you could have used was you take this hot plate and then you just keep it on a cold object. In both the cases, the plate will cool down. This is also cold and this is hot plate. And this is a cold fluid. And this could also be fluid or could be a solid as well. Where do you think the object will cool down faster? Case number one or case number two? OK, Shrestri, which one? One or two? The answer is that it is one. So in two, there is conduction going on. Here, it is an example of convection. Now let's see why. Why at one, the cooling is much faster. What happens at one is that the cold fluid come in contact with the hot object, then takes the heat from the hot object. This fluid also heats up and then goes away. And then a new cold fluid will come. Earlier, this cold fluid was there. Now, this portion has taken heat and gone away. Now, a new cold fluid is coming. Again, this is cold. This gets in touch with the hotter object and then takes the heat and goes away. So what happens is that temperature of the cold fluid is let us say Tc and temperature of hot fluid, hot object is Th. So Tc is remaining constant. Even though it takes heat, but then after taking heat, Tc increases because the fluid is absorbing heat, but then it is going away as well. A new object comes in, a new fluid comes in and it further absorbs heat. So because of that, Tc remains practically constant. And heat transfer will happen because of the temperature difference. Over here in case 2, hotter object, when it comes in contact with the colder object, temperature of hotter object goes down and temperature of colder object will go up. So the difference between hotter object and the colder object, it decreases at much faster rate in case number 2 because temperature of hotter is going down and temperature of colder is going up. So the temperature difference is decreasing from both ends. Whereas in case number 1, in convection, Th minus Tc is the temperature difference. Only Th is going down. Tc remains practically constant. So the case number 1 is a new type of heat transfer where what happens is, please write down, bulk movement of fluid over an object transfers the heat. So in the conduction, we never taken the case in which the fluid is moving. But several cases, wherever we want higher heat transfer, in that case, the fluid is actually moving. That is not an example of conduction, but that is an example of convection. Now in our syllabus, luckily, we don't have extensive study of convection. Just few examples of convection are there. So in case they ask you in your school exam with respect to give example of convection, then you need to talk about natural convection. Please write down. So what happens is natural convection is a process due to which naturally the convection current will flow. And let's see how it happens. For example, let's say this is C. It is C, huge water body is there. And this is the she-shore.  This is coconut tree. And this is you. Fine. Suppose sun is there. Okay. What happened? Because sun is there, the specific heat of water and let's say this is specific heat of land. I know that specific heat of water is very large compared to specific heat of solid usually. So during the daytime, what happens is tell me whose temperature will move up quickly, the temperature of water or temperature of land. Which one will go up quickly? The sun is there. The temperature of land. The temperature of land will go up faster because specific heat of land is lower. Okay. And hence, temperature of land is typically higher than temperature of the water or temperature of the sea. Okay. So because of that, the air in contact with the land. Okay. The air that is in contact with the land, this air. Let's say that is AL. And this is in contact with water. Let's say AW. Which air will be lighter? Sorry, which air will have more temperature, which is in contact with higher temperature object. So temperature of air of land will be higher than temperature of air of water, right? Because of which density of air of land will be lesser than the density of air of water. Is it true? Are you able to understand? Yes. Okay. So what happens because of this? The air which is in contact with the land is at much higher temperature than the air which is slightly above. So because of that, the air which is lighter or density is less tends to move up. Okay. This happens because of gravity. This moves up. Now, because this air is moving up, because this air is going up, what happens is that pressure over here decreases because air is moving up, all right? And since pressure over here at the land side is lesser now, the air from the water side will start moving to this side because of the pressure difference. Okay. And this creates an entire cycle. Okay. So what happens is that when you are near the sea shore during the daytime, the air will tend to flow from sea to the land. Okay. And you can clearly see that the air which is cold is coming to cool the rocks which is near the sea shore and this cooling process is a convection process because there's a bulk movement. Is this clear to all of you during daytime what happens? Yes. Yes. Now let's see during nighttime what happens. During nighttime, suppose this is sea. This was a previous slide for one second. One second. Okay. I'm anyway going to send you this. Don't worry. This is your coconut tree. Same coconut tree. And now there's a nighttime and you're still standing here. Now what will happen is that during the entire daytime, the water was getting heated up and the land was also getting heated up. Okay. What happens is when the sun is set, the source of heating up the objects have gone now disappeared. So they will start cooling down. So during the entire day, water was heating up and the stones were also heating up. So at some point in time, temperature of water became equal to the temperature of the rocks finally and then they have started to cool down during the nighttime. Now tell me which will cool down faster? Land will cool down at faster rate because specific heat of land is lesser. So it will lose out. If it lose out X amount of heat, its temperature will go down faster rate because it's specific heat is lesser. You can write down X is equal to M s delta T. So delta T, which is temperature change will be X divided by M into S. So you can see that for same amount of heat that is losing away, change in temperature depends on S as inverse proportion. So if S is less, delta T for same amount of heat absorbed or lost will be higher. So now it is about losing heat. So rocks will cool down faster than water because of that the temperature of air near land will be lesser than the temperature of water. Sorry, temperature of air near water. So what will happen is that now temperature of air is higher over here. So this air will move up because of the pressure difference now air will go like this and just to complete the cycle it will take a turn like that. So this is again a natural convection. Now what will happen is that the colder air from the sea shore is going towards the water to cool down the water using convection. So during the night time the air will flow from land to the water. Is it clear? Any doubts you have? Please quickly ask. No doubt. Fine, so that's it with respect to convection.