My name is Rick Howard and I am the eye defense general manager. Eye defense is a open source cybersecurity intelligence shop. It's a business unit of the Verisign. We're going to talk about insider's look at international cybersecurity threats and trends. Okay, but this is really what we're talking about. Open source hacking. We're not talking here about hacking code. We're really talking about finding information by just kind of perusing around and talking to people, finding out what's out there in the open and putting the stories together. All right? So these are the three things we're going to talk about. Two case studies, operation aurora and stuck to that story. And we're not talking about the hacks that went involved there, but really the impact of those stories. And finally we're going to talk about what we think is coming down in the future. This is something called a cybersecurity disruptor.  First that cyber espionage is a real world threat to the commercial industry. Now, most of the people in this room know that already. Okay, but, okay, most of the commercial industry didn't really know that until Google went public with their hack back in early 2010. The second one is that cyber warfare is not no longer a theory more, but a fact. Now we're talking about nation states declaring cyber war on each other. What we're talking about here is actually being able to do cyber warfare activities to critical infrastructure. We'll talk about that. And finally we'll say some new technologies, ideas, policies coming down the pipe that are going to make us change, fundamentally change, how we protect the enterprise going forward. Before I get into this, I know this is a fairly technical audience, but I also know there's a bunch of government folks in here and some lawyers, so I want to get a feel for how technical the crew is. So show of hands here. How many people have one of these phones on their pocket right now? Okay, how many have two? All right, how many have three? Okay, okay, okay, the real geeks of the crowd right over here. All right, how many have this phone? Raise your hand. Okay, some of the lawyers and a couple of government guys back there. All right, so I declare that you guys are technical enough to get this presentation. All right, let's start with Operation Aurora. Okay, the reason I like to talk about Aurora is because this attack fundamentally changed how we all think about the enterprise. It completely changed the entire thought process of the commercial industry. Okay, so it made it, there are actually five different things that made this attack unique. There's been a bunch of attacks after this that kind of go along with it, but this was the first one that caused everything to change. And the first one is that Google went public with the information. Can you imagine any other commercial organization doing that? All right, that has never, ever happened before. All right, and they went public who they thought it was. They said the Chinese government went after them. Okay, that's never happened before in a public forum. So that made it kind of scary. It made the whole operation a little bit different. Okay, and before Google went public with this, most commercial companies thought if they went public with this kind of information, their reputation would be damaged in some form. Okay, when Google went public and said, you know, about 20 companies were hit by this attack, defense contractors, information technology companies, banks, chemical companies, and then that's what they pretty much smashed the entire paradigm about how you report this kind of thing. In fact, Google's reputation went up if you remember. Everybody thought they were the bee's knees when they went public with that information. And they got support not only from the private sector, but from the government sector. Okay, so this has never, ever happened before and it caused us to change how we think about the business. All right, the second reason was the US government support. Secretary Clinton came out immediately after Google went public and gave them public support and said we think Google's right and we think China's behind the attacks. Okay, now the government's known about these kind of attacks for a decade, even over a decade at this point. They've had really cool code names like Moonlight Maze and Titan Rain to talk about cyber espionage attacks that basically the bad guys come in, collect all the information and bring them back to some nation state or further analysis. Okay, in fact, other countries besides the US have outed China before like Chancellor Merkel, but never for a specific attack. Just sort of a general, we know you're doing it and we want you to stop kind of a thing. Okay, but the secretary Clinton on this attack said we think China did and we want them to stop. All right, she actually in two public forums, okay, said we're coming, we think you guys did it and we want some answers for you in two different times. Okay, she's pretty much picking a fight with them. She's actually traveling through Asia, this whole thing was going down. All right, and she met with her counterpart for China and after a three hour long session, they came out and said this quote, and I like it, anytime two politicians come out and say they had a very open candid conversation about something, that means that conversation was tense. That's what I'm thinking. Okay, number three. Okay, the Google asked the NSA to come in and help them. Okay, think about that. All right, we got a couple of chuckles over here, right? Yes, Google asked the NSA to come in and help them. Now to be clear, the NSA came in and helped them with security expertise and how to defend the perimeter and best practices and those kind of thing. There was no intelligence gathering about that. All right, but the program was so successful that the NSA formalized it into something called perfect citizen. All right, that means that any U.S. company that has trouble trying to secure their perimeters, they can call the NSA and then they will send Raytheon contractors out to help them figure this out. So they do vulnerability assessments and capabilities research. All right, so that's something that's never ever happened before and something that makes it very unique to this kind of an attack. Number four, this is the wake up call for the commercial industry. Like I said, government knew about it for over a decade. Most commercial organizations didn't really want to talk about it. They would always say, what do I have to steal? Okay, but after the Google thing came out, they all realized they have all have intellectual property they need to worry about and protect. And we learned about this new phrase, the advanced persistent threat. Okay, everybody know the trivia why we call it the advanced persistent threat? Anybody know the story? Okay, like I said, the government has these really cool code names called moonlight maze and Titan rain. And in fact, Byzantine Hades came out in the WikiLeaks documents last year sometime. These are all code names that mean that refer to the same kind of attack process. But what happened was the government had no way to communicate this to the commercial sector. So they had to have another phrase they could use to do that. So some very smart Air Force major said, you know what, we're going to start calling it the advanced persistent threat. And that's why that term got coined. So that's why we all at this new buzz phrase, we're all our entire industry. I call it cyber espionage. Okay, that's what it is.  In fact, it's such a big deal that APT was unheard of before the Google attacks in 2010. But by the end of 2010, security leadership and big companies are saying, APT was their most worried about threat in their company. Which brings us to five. Maybe after attribution isn't as hard as we always have thought it was now it is hard to get to figure out who it is. And I do not know who did the attacks against Google. Okay, nobody knows that in the public forums. Okay, but maybe it's not impossible to figure this stuff out. You got to think that if someone as high as Secretary Clinton is outing China in public forums that she had her confidence was pretty high that she know who did it. Right now I'm not saying she didn't know how to do it. And she may have had some other political levers she wanted to pull. But I'm just saying confidence should have been must have been fairly high for her to make that come true. It's pretty much triple dog dare them to do something about it. Alright, so maybe actor attribution is hard, but maybe it's not impossible. Alright, so the five things that made the Google attacks really a game changer for our industry is that Google went public, no commercial organization would like to do that. The US government publicly backed Google in their affirmations. The NSA and the Google formed a partnership which became a formal program. Okay, and the commercial industry probably woke up and said, you know what this advanced persistent threat stuff is real and we need to do something about it. And finally, maybe actor attribution isn't as hard as we originally thought. Alright, so that's all about cyber espionage and how the commercial industry has really come come to terms with this new kind of threat. Let's move over to Stuxnet. Everybody knows about Stuxnet has been the in the news for the last year or so, but let's just kind of go through the timeline a little bit. Alright, so this is back in June of 2010, an anti virus company called Virus Blockada. Alright, now Virus Blockada is a Belarusian antivirus company, and that is the best name for an antivirus company ever.  Come on, that's funny. That's what I thought. Okay, so they come out in June of 2010, and they say there's a new piece of mail code out there called Stuxnet that targets Siemens industrial control systems. And these are the SCADA systems that we've been all been talking about for the past decade. We've all known in this room that SCADA systems were insecure or insecure. Alright, so finally someone did something in the world to prove it. This is supervisory control and data acquisition systems. Alright, and if time moves forward a little bit in the September of 2010, the security community, that's you people in here started to say, you know what, looks like this might have been a nation state attack.  This is somebody that had resources, and they were trying to have a they were trying to get something accomplished. Right, in fact, they were targeting the Natanz power plant inside Iran. Alright, and the reason is Natanz produces enriched uranium, and it looks like the people that launched the attacks are trying to decorate their ability to do that. And the reason is if you take a look at Semantic, Semantic did the bulk of the work on this on pulling the mouth of the part and they really hit the ball out of the park for this. So those guys that did that might have this off to them. This is a chart from their dossier on what happened with the with Stuxnet. And it's hard to read, but let me just tell you what it means. They show that Stuxnet kind of floated around the entire world, but the bulk of it ended up inside Iran, that pink circle there, and that darker red that is Iran 60% of Stuxnet infections were inside of that country. So maybe it was targeted attack inside of Iran. Now these two Semantic and partnering with Institute for Science and International Security said, this is how we think they got the Stuxnet into the power plant inside of Iran, because the power plant was not connected to the internet.  That's probably true. Okay, but the attackers targeted the supply chain from the attached power plant. They went after four companies inside of Iran that supplied materials into the power plant and waited for it to percolate into the plant. And that's what they did. First strike for Stuxnet was somewhere June 2009, because when the first infection started to show up inside of the tans. Now the UN likes to watch in the tans because they're very worried that Iran is trying to produce an atomic bomb there. So they are watching very carefully how much uranium is produced in that facility. Okay, in their estimate between 2009 and 2010 about a thousand centrifuges were destroyed by the Stuxnet malcode. And that was just the beginning. In fact, if you listen to some of the stuff that Symantec has said in the Internet, the Institute for Science and International Security ISIS, okay, they think there are probably two attacks, two attacks to begin. There was one in 2009 that was the initial launch. And then in 2010, there was a second version of code inserted into the tans. And nobody's really sure what that second version did, but it was definitely an upgrade to the initial code. Now, this is what I'm talking about. This is where we have moved from cyber warfare going from speculation and theory to proof of concept, I mean to real being a fact out there. All right. Now, the reason I'm saying is now possible to use a cyber vector alone to destroy critical infrastructure. We have not seen that in the real world really until the Stuxnet attacks. We've had demonstrations of that capability. These are the ones everybody trots out, the Estonia attacks, the Georgia attacks. You can even look at the Department of Energy's Idaho lab.  Everybody seen that video on YouTube? You can see it if you watch Pretty Impressive but watch that thing destroy itself. But that was in the lab, scary, but no one's really done it in the real world. With Stuxnet, it is now in the real world and we need to worry about it. And the code, as you all know, is extremely sophisticated. Now, this is one of my pet peeves. When someone like me stands in front of a crowd like this and says something was sophisticated, what's the first question you should ask? Compared to what? Because if nobody tells you what it's sophisticated to, then it really doesn't mean anything. Everything is sophisticated. Let me tell you why Stuxnet was sophisticated. There are three really big reasons, okay? There were four zero days inside that code. We're not talking about the code that did the damage to the centrifuges in the tanks. We're talking about the code that got them in. Four zero days. At iDefense, we track how much that kind of stuff cost on the underground. And it can go anywhere from the total cost of this package anywhere from $400,000 to almost $2 million just for the zero days. Okay, so somebody built that stuff themselves or paid to have that stuff built, or most likely it was a combination of the two, but they were well financed in order to get this organization, this malco, into the power plant. The second, they use new technology that we had never seen before. Windows Server 2008 and Windows Vista, Microsoft introduced the new idea of driver signing. The idea would be that if I have a third party writing for Microsoft, they would sign their code, and if a kernel would check it when it ran, if it had a valid certificate, then it wasn't malco. Okay, what these guys did was sign Stuxnet with two different certificates from two legitimate companies. Okay, and that got through the radar. All right, and if you want to get the conspiracy theorist out here a little bit, those two companies, RealTech and J Micron, they are within a block of each other inside of Taiwan on the technology corridor. Okay, a block from each other. Now that kind of points to the fact there may have been an insider person trying to grab those two certificates, right? We have people on the ground in those areas and we know that there are lots of intelligence ACs that like to hang out on that little corridor because there's all kinds of interesting things going on there. Okay, so put that in your conspiracy app. All right, when Microsoft and Verisign noticed that those certificates were bad, we revoked them. Now, I just want to point out as an aside, look at that Verisign logo. That is the old Verisign logo. You look at the bottom right of my slide, you see the new Verisign logo. Okay, we sold that part of the company to Symantec last summer. That's their fault. All right, in fact, this is such an interesting new trend. We've seen the bad guys on the cyber crime side start to use this technique to steal your credit card information too. So it's a new technique that we started to see with Stuxnet. All right, now number three, this is the first root kit we've seen in the real world, targeting SCADA systems. Okay, now think about what this thing had to do. Okay, what they were really trying to destroy was the centrifuges inside and the tans.  Inside those cascades are 164 centrifuges. And what they do is they spin around really fast between the frequencies of 807 Hertz and 1210 Hertz. And you put uranium gas inside the centrifuge, spin it around really fast. The heavy atoms collect to the outside and the technicians pull that out. That's enriched uranium. Okay, and you need to enrich uranium to build nuclear power and you need enriched uranium to build a nuclear bomb. In fact, 90% of the nuclear bomb has to be enriched uranium. So this Stuxnet code was looking for these specific centrifuges running at these frequencies. And in fact, if it didn't see it, it wouldn't do anything, it would just stay dormant. Okay, but if it did find it, it would do some damage to it. Okay, in fact, it was looking for two specific motors running these centrifuges. One built by an Iranian company called Ferrara Paya. I mean that's my best guess at that. And another Finnish company called Vekon. If those two motors weren't there, Stuxnet didn't do anything. It just sat idle. But if it did find it, okay, it went after the centrifuge itself. And what it did was it would spin the centrifuge up to at max speed as fast as it can go and let it run there for about an hour. Okay, and then it would drop it down to normal and let it sit for 30 days. Okay, and then it would drop it down to two hertz and run it at a very minimal speed for about 30 minutes. And then would pick it back up at normal speed and let it run for 30 days. And it would do that over and over and over again. Stuxnet would sit in the middle between what the controllers were telling the technicians. All right, and then when the controllers say, hey, this isn't working very well, it would intercept that message and tell the technicians that everything was a okay. All right, the centrifuges, okay, are very precise equipment and they started to fail immediately when these things started to happen. Okay, so that's why Stuxnet is sophisticated. All right, so well financed, new technology, and the first piece of Malco we've seen targeting SCADA systems and very specific SCADA systems are running inside of the Natanz power plant in Iran. All right, so let's go back to the timeline. Virus Blockida announces to the world that Stuxnet has been discovered in June of 2010. Okay, if you go down just a month now, the Microsoft and Verisign, they revoked their certificates from real tech. Now take pay attention to the timeline, this is where it gets very interesting. Okay, this is July 16th, I can't even read that, but somewhere in the second week of July. Okay, the very next day the attackers installed the second certificate. Okay, the very next day that implies there's a punch counter punch going here. The attackers were anticipating that someone's going to discover that they were ready to install a new one and did it immediately. Now that's not enough to convince you. Okay, on the same day, denial of service attacks were launched at two very prominent SCADA forums on the same day. It's as if the attackers were trying to prevent the community from talking about it. All right, so think about that. That is a battle plan going on here. That is a punch counter punch. The attackers were ready for that and they had something in their back pocket to counter it. All right, finally Microsoft and Verisign revoked the second certificate and make the mouth code not installing any new copies. So let's fast forward into September. This guy, Hamid Alipour, he's like the CTO or CIO or CSO of Iran and he reported in the public that almost 30,000 computers were infected with Stuxnet. And the UN watchdogs reported that at least half the centrifuges in the detached power plant were idle. That's half of 9,000 centrifuges. Okay, so Stuxnet was having its effect. All right, so fast forward into November and this is where it gets very interesting. The technicians inside the detached power plant, they shut the system down for over 10 days, presumably to get rid of Stuxnet off the network. So they go, they turn it back on after a week and then hold your hat. This is where the conspiracy nuts come out of the woodwork here, okay, because this is the next step in preventing Iran from producing enriched uranium. They assassinate or at least try to assassinate two scientists in Iran. These two scientists were coming to work in the morning. Okay, motorcycles pulled up alongside their car, attached bombs to their car and blew them up. Okay, the first guy, he's dead, okay. The second guy in critical convention, all right, and many survived and he eventually takes over the program later. So think about what this means though, all right. The attacker's goal was to stop uranium enrichment going on in the tanks. They threw a cyber vector in there with Stuxnet. We're able to damage it for a while, slow it down when the Iranians shut down the net and took it off the network. They went to the next step and started going out to their personnel. Okay, this is the first time we've seen a cyber record like that associated with that kind of violence, okay. So we are in a new world, ladies and gentlemen, okay. Something kind of scary. So take a look at the battle plan here. This is kind of the long range view of how the attack happened. Okay, you got to admit that there was some planning going on here. So there's the campaign planning sometime in 2008 probably. The first strike in 2009, second strike in the spring of 2010, and that's when right about a thousand centrifuges were first destroyed. Then comes the next skirmish in the battle, the battle for the certificates. The good guys find out where at least the victims or the professional security community said, oh, we know it's bad. Let's revoke the certificates. Bad guys put a new one in. We take that one back out. So that's a kind of a skirmish going on there and the denial service attacks. The fourth one and finally is the Natanz coming offline, going back online, and then the attackers going after the Iranian scientists. Okay, what I'm trying to show here is this was an adversary who had a battle plan. They knew what they wanted to do. Okay, and they had backup plans in case something went wrong. And I hope you can see that in that timeline. So the question is how effective were the attacks? According to the U.S. and Israel, the nuclear program in Iran was delayed until 2015. Okay, but according to ISIS, there was no effect even with all the damage and all the delays in the Tanz. The Iranians were still produced as much uranium, enriched uranium, as they were supposed to produce. The truth is it's probably somewhere in the middle. We probably won't know for a couple of years. All right, so what do we get about all this? First, that the Stuxnet attacks were sophisticated. Okay, a new technology, well-financed and targeting SCADA systems. At your dinner party tonight, one thing you could say that's interesting is we don't think it's China and we don't think it's Russia and that's kind of refreshing. It's usually those guys in the spotlight. Okay, so it's probably not those guys. But the real thing you want to get out of this is that cyber war has moved from theory to fact.  So we are in a new ballgame.   Okay, good. Let's move over to the cyber security disruptors. All right, so what is a cyber security disruptor? Well, this guy, Clayton Christensen, he wrote this book called The Innovator's Dilemma in 1997 and it's about business disruptors. His theory was that there were new things coming down the pipe that fundamentally changes the business and what that thing is is some new innovation that nobody anticipated. Okay, and what happens is it makes the entire community have to change how they run their business. Okay, and what happens during this process is some businesses that are not ready for the change, they fail because they aren't fast enough to pick up the pace. So they don't catch the wave and fast enough to make the change. All right, so these are new business catalysts and these aren't slight improvements to technology but radical new changes how we do it. Now any math geeks in the world, in the audience? Math geeks, come on. Okay, what is that symbol? That's a radical. Come on, that's my joke for the day. Radical and okay, forget them. All right, now these new technologies, they are really niche when they first come out. Okay, but over time they build momentum and the best practices that we've had in place wither and die as these new things take their place. Now the example that Christensen uses is the reduction of hard drive size from the 1960s to the 1990s. The one I'm going to talk about here is the battle for the five and a quarter inch disc and the eight inch disc. Anybody old enough in the room to remember the first IBM PC marketing campaign? Okay, they used a little tramp as their, as their, okay, got some old guys in here. I know but you're old enough to know that. Okay, all right. You guys are probably carrying these phones. Okay, that's older than that. That's right. All right, so the dominant floppy drive at the time was the eight inch floppy drive and that was used in many computers at the time. These things were high end and cost a lot of money. Okay, the, is that me? It's not me. I swear it's not me. All right, so when IBM built the first PC they decided to go with the five and a quarter inch floppy commercial off the shelf really cheap. Okay, and what happened is that the manufacturers of the eight inch floppy didn't really anticipate the demand and these are the four companies that were making floppy drives at the time. Only one of these guys survived in Micropolis and according to Christensen they only survived through Herculean efforts by the management team to turn their plans around to start producing five and a quarter inch floppies. So that's what a business disruptor is. New innovation that comes out that completely changes the business. Like again, not slight improvements but radical changes in innovation that make everybody change. All right, so that's what a business disruptor is. At iDefense we think there are cybersecurity disruptors. New ideas, policies, technology, events coming down the pipe they're going to fundamentally make us change how we protect our environments. These are cybersecurity catalysts and we're expecting five to ten years down the road for these kinds of things. Again, now this is the important part about a cybersecurity disruptor. Okay, these aren't just new ideas or things. These are things are going to make us change how we do our business. So unless they make us change they don't count as a cybersecurity disruptor. All right, so iDefense have identified up ten of these things and these are them we're going to talk about a couple of them in this pitch. All right, now I think you have to remember about cybersecurity disruptors. Think of them in terms of a triple. Okay, you've got to worry about what the concept is. So the concept might be the mobile platform.  And finally, the last part of the triple is how is it going to make you change your security posture? So that's what a triple is. Is that really me? Oh, they're doing VoIP. Okay, I was going to say I am an expert buttyler by the way. Sorry. I know I went too far on that. Okay. All right, so consider this timeline. Okay, at the far end is the event horizon 2020 10 years out is about as far as we want to go predicting these kinds of things. 2005 is really where our best practices are. Okay, these are the things we all have in place in our environments to protect our enterprises. These are things like firewalls, intrusion detection systems and antivirus stuff. Okay, in the middle here 2010 2011 is where leaders are making decisions about what technology to bring into their enterprise. Okay, and this is where we're trying to help out here. The thing to remember is that there are going to be early adopters of these cyber security disruptors. Okay, these are folks that have realized that this technology may not be ready for their environment. There's going to be lots of bumps and bruises as you install it but they feel there's a need and they need to have it already. So there's going to be early adopters. All right, I'm not going to talk about all 10 because that would take the next five hours. We're only going to talk about three of these things. Remember, we're going to talk about triples and I'm going to tell you about when we expect to see them and if there are any early adopters. The first one is the combination of top-level domain extensions and international domains. All right, so the concept is let's talk about top-level domain extensions first. Up to this point, we've had the traditional dot com dot net dot biz dot edu in about a year or so you're going to start to see a bunch more. Okay, if you have enough money, you can have your own top-level domain. It could be a dot Rick or it could be a dot Defcon or it can be a dot I don't care. It doesn't matter if you have enough money and they're going to be expensive. Okay, there's going to be these new names out there that we're going to have to contend with. And coupled with that is this idea of international domains. Up to this point that all the domain names that we've had have been in English. Okay, but from 2012, 2013, you're going to start seeing domain names in Chinese, in Farsi, and in any kind of other language that who wants to play with this kind of experiment. So those two things together is the concept here that is going to make it a cybersecurity disruptor. The impact here is this is just one of them probably for this combination is that Blacklist are going to be unmanageable at the enterprise because you're just not going to want to mess with this anymore. You're not going to have the wherewithal to deal with it. So the change in your environment, we're going to start to see companies outsource their Blacklist capability to cloud computing folks. Okay, so that's that's what we expect to see. All right, probably you're going to start to see these services merge inside the your enterprise by 2015. And this year and last year ICANN has authorized this. These two things from happening, the top level domain extensions and the international domains they keep pushing the line back a little bit but expect to see it in 2013 by the latest, I think. All right, let's talk about oh IPv6 and domain name the DNS sec extensions. That's what this is. All right. So that's the concept. DNS sec extension even to any of the Kaminsky talks, you know that that's coming down the pipe. The top level domains are ready for that kind of thing and the introduction of IPv6, the new IP protocol that's going to replace V4. What that means to the enterprise is that IP management has just become very complex. Okay, and the change is your this guy you have in the basement managing your DNS system is probably going to go away okay. And you're probably going to want to outsource that stuff to some cloud computing environment also. All right. So expect to see this kind of thing in 2013 in 2010. Okay. This is a Gartner chart. Let me just read. I know it's a hard thing to read. Let me tell you what that means. The green line is the size of the internet. The blue line is the size of the IPv4 pool and the v6. I mean the red line is the v6 deployment. Gartner predicted there'd be two to five years in this is in 2010 now. They predicted we had two to five years before we ran out of v4 space. That happened last year. There are no more v4 addresses. Okay. So for the next couple of years there's going to be sort of a black market as companies sell their v4 space that they're not using. But eventually we're going to run into v6 and we're going to have to manage it. Okay. All right. Next is APT. I talked about the APT with Google. That's the concept. Okay. The impact is and I think this is what the commercial industry has really figured out. Okay. That their intellectual property is seriously at risk and we need to do something about it. And the change for their environment is I think data loss prevention systems are going to start being installed by the number. Okay. Through the enterprises. We're going to start seeing that around 2013 this is going to be best practices. There are early adopters now. People are deploying this technology right now but they're they're getting scarred by it because it's very complicated and very expensive but they're learning the lessons for all of us as we start to do this ourselves. Okay. And we talked about Google in 2010 and why that was important. All right. So that's cyber security as rubbers. Let me just put all of them on the timeline here just so you guys can see them. This is where we think they're going to be in the next 10 years. And this is where the early adopters are. Real quick. All right.  New ideas, technologies are going to make you fundamentally change your enterprise. And I talked about three of them here. All right. So I'm at the end. Let me recap a little bit. These are the three things I want you to get out of that. The commercial industry should have awoken by now that cyber rescue now is a real threat. That cyber warfare is real and not that nations have declared cyber war on each other, that it is possible to destroy physical stuff on the in the world with a cyber vector alone. And there are new things coming down the pipe. They're going to make you change how you do your business. Let me just finish up. But we've written a bunch of books at that defense. Please buy them. I have to put my daughters through college. And if you want any more detail information about some of the stuff I talked about here, that white paper down on the bottom right. I will gladly give it to you. Just email me or come see me afterwards and I will gladly get you a copy. So that's it. Thank you very much. And we're done here.


Welcome to Kalusugan ay Karapatan with another exciting episode today, geriatric issues and senility. Our episode today is about the elderly and how they should be given medical care. But did you know that it is difficult to define the elderly age group precisely? Some people do not want to see, some people do not want to use the word aged or elderly or senile because they may be derogatory or may connot certain incapacities or physical defects or looks that may be contested by older people themselves. That is why I think the appropriate word is older people which is sometimes preferred but is equally imprecise. 60 to 65 is the age often used to describe older people but most people do not need geriatrics expertise in their care until age 70 or 75. Like many people, I know even they are in their 70s or 80s they still look like glamorous, 40s or feel like they are teenagers. That is true, Commissioner Lili. You will be happy to know that overall women live about five years longer than men and this may be because of genetic, biologic and environmental factors. Although there have been changes in women's lifestyle such as increased smoking, increased stress, still these differences in survival rate over the late 20th century has not changed much. Still we need to confront the fact of life that aging is inevitable. The functions of our organs will decline over time and this will be irreversible even in the absence of injury, illness, environmental risk or poor lifestyle choices such as unhealthy diet, lack of exercise, substance abuse, etc. Aging organs are also more susceptible to injury such as intracranial hemorrhage. We need gerontologists, those who study of aging including biologic, sociologic and psychologic changes. It is good we have invited resource persons to shed light about gerontology, geriatrics and other terms related to older persons. Yes, I cannot think of anybody who can make our audience understand better what aging is because she's the director at Institute on Aging National Institutes of Health, UP Manila. Beside that, she's a professor at the University of the Philippines, president of the Philippine College of Geriatric Medicine and director at Institute of Health Policy, NIH, UP Manila. It is my pleasure to introduce a good friend of mine, Shelly de La Vega. Shelly. Hello and thank you for having me here, Chancellor Padilla and Commissioner Dili de Lasliagas. I was the former policy director and the former president of the College of Geriatric Medicine. But still, I'm the incumbent director of the Institute on Aging at the NIH, UP Manila. I also have the privilege and honor to introduce somebody who will compliment Shelly de La Vega's expertise in aging. She's an adult neurologist and her subspecialty is memory disorders. She is the head of the Center for Memory and Cognition of the Philippine General Hospital. She's been a doctor since 1998. Ladies and gentlemen, let us welcome Dr. Vida Michelle Anlakhan. Thank you Chancellor Padilla. Hello, Dr. Lili. Let us now ask Dr. Shelly about the mental and physical abilities of older people. What happens to them at the age of 65 or 70, Dr. Shelly? All right. We have what we call physiologic aging and chronologic aging. Now, chronologic aging happens from birth. In fact, aging is something that we all go through. From the time we are conceived in the womb. So aging really happens from womb to tomb, unfortunately. And there are people whom we know are very healthy, as you mentioned earlier, despite their age. So not all 65-year-olds will be frail and weak and have problems with their memory. Many of them will be very active when we talk about geriatrics and the geriatric age group of 60 and over, we sort of think of them as in three categories. The young old, the middle, and the oldest old. So many of the Filipinos are in the young old category. These are those who are still working, still active, pursuing their careers and very, very much attuned with what is happening in the world. These are usually those age 60 to 70. At age 70 to 80, 85, then they start having chronic degenerative problems manifest as weakness or frailty, which I can explain later on. At the age of 85 and older, we have the more frail older person. These older persons now start to get sick and get hospitalized and really start to get more dependent in their activities of daily living. So they may need a caregiver at this point. But still, like I said, aging is very variable. So we cannot say that all 80-year-olds are this way because I know of patients of mine who still run marathons at the age of 83 and 85. So there are some outliers there in that what we think is a normal curve to describe aging. Is there a way of, you know, it sounded like a very healthy young old person that you were describing. Are there ways of preparing for this so that we will have healthy aging? So healthy aging is a concern of everyone. Like I said, it should start when we are conceived.  And we need the environment and the health system, a good educational system and possibly behavioral, you know, behavioral and personal choices that would allow you to live a healthy life. So intrinsically, we have the genes that will sort of determine what illnesses we may have, how long we will live, but genes will only take up about 30% of what determines our aging process. Much of it has to do really with your lifestyle, the environment and the health system that surrounds a person. How do we prepare and be healthy and active up till we are 85 years old? I think, like I said, as a young child, we need to really support maternal and child health. And as young adults learn certain habits, hopefully we get rid of certain habits that promote early aging and sicknesses such as smoking, extreme alcohol, intake, risky behaviors. And if we have a good educational system, a good educational system and a health health system that allows universal healthcare, for example, then that will more or less assure us that we are in a good trajectory. May I ask, I don't know if I am suffering from early aging. How would I know that I am not? A lot of people have different parts of their bodies age differently. So we age differently from the person next to us, but even parts of our body can age differently. So you may have aging joints. If you, for example, have been obese most of your life, possibly by the age of 40, you will start experiencing arthritis of your knees and hips. So those are early signs of aging per se, joint problems, hypertension, elevated cholesterol, poor vision, and maybe eventually later on as we discuss failing memory, those may be some of the manifestations of early aging. But maybe you are concerned about premature aging, right? I still remember you. Okay. So there are signs of premature aging and like I said, you can go to your doctor if you are having all of these aches and pains because arthritis pains are the number one health complaints of older persons. So and of course, blood pressure, uncontrolled hypertension, high cholesterol, these are all, you know, things that we can manage early. But Patino, I think inevitably all of us will grow old. So the goal is health aging, but what we fear most is actually if we go into an issue of dementia or senility and I want to turn to Dr. Anlakan to explain to us what is dementia and what is senility.  If you have problems with day-to-day activities like counting, banking, handling your money, keeping track of your medications, traveling from place to place or using appliances, then you may already have significant memory problems versus just getting old. But when we get old, usually our memory is still intact. That is the norm. That is supposed to be the norm. It becomes abnormal if there is already an impact on our daily activities. I forgot my key. I placed it in the refrigerator. I am already experiencing dementia. Unfortunately, Commissioner Lily, it goes beyond that. It goes beyond that. It cannot be just forgetting where we placed our cell phone, our eyeglasses, or our keys because I think all of us will fall in that criteria because we are all guilty of occasionally having those problems. So the defining line is actually functionality. For example, if you are a doctor, you are still able to function very well. Do your clinics, do your rounds.  At the end of the day, it's really functionality because if you have impairment, then you really need to see a doctor already so that certain diagnostics have to be made. What's the earliest sign at what age does it set in? There is no actual age, but there is a usual age. Usually it's above 60. Okay. So senior citizens, if they are in doubt or if they feel that they have declined from a previous level of functioning, they should already consult. Sometimes we don't want to wait for the time that you can no longer recognize family members or you cannot recognize people or you cannot do your daily activities. You don't wait for that. The moment you feel that you do have a memory problem and there is an impact in your life, you should consult because initially, we screened for reversible causes. There are reversible causes. Unfortunately, if the workup is all negative, then that's the only time we say that this is neurodegenerative dementia usually of the Alzheimer type which is the most common. And yeah, so we prepare you and your family to deal with this because this is going to take a long time. What's the reversible checklist? The reversible checklist are usually hypothyroidism. A lot of people have had thyroid surgery in the past and then they forget about taking their supplementation for their thyroid hormone. And then sometimes they have infections in the brain, HIV, Neurosophilis, they are still common. We see, we still see them. We also usually use that to check for vascular risk factors. Heart disease, hypertension, diabetes, hypercholesterolemia because the risk factors that give you a heart attack and a stroke are also the risk factors that will give you dementia. Wow.  If you have tumors or cysts that can actually affect your memory. So you need a neuroimaging so that you are sure of what diagnosis you're dealing with. In the usual Alzheimer case, what we just see is atrophy. There is shrinkage of the parts of the brain dedicated for memory. Okay, so I have a question like forgetting names of people you've known in the past. Is that an early sign? I mean, I think that's very common. Yes, but is that an early sign of dementia? I also get that question a lot. Unfortunately, people are different. For example, you meet a lot of people every day and then you don't really work with them too long for you to be able to retain their name or their face. And also you compare yourself to your previous level. Have you always been retentive to names and faces? Because if you have been, you should still be now. But if you were never a good person to remember names or correlated with faces, then you have to be more forgiving of yourself now. Especially if you have only limited contact with people, knowing them for a short time, working with them for a short time, then you may really forget that is part of normal aging. If you want to remember, you really have to put effort on it. So I'm hearing, I mean, if I work and invest on healthy aging, can I assure myself, our selves that you will have a lower risk for dementia? Yes. We actually have scoring systems for what are your chances of developing dementia? Recently, there have been a lot of studies on prevention of dementia, highlighting certain things that are modifiable as we get older. I think that's good for us in the relatively intact stage so that we don't cross over to the persons with dementia stage. I think we can still prevent a lot of these modifiable risk factors. Every day, I talk to people. I remember the names because I try my best to remember names easily. But I have a friend. She cannot remember the person she interviewed. Is it because she has no propensity to remember names or is she experiencing early dementia kaya? We don't know. It has to be a consistent problem and you have to gauge her based on her previous level of functioning. So if she's always been like that, then we have to forgive her now. Because she's always been like that. Yes. Some of the tips that we know of can increase your life expectancy or your healthy life expectancy by two years. If you do these things part of which includes eating breakfast, having a good breakfast that they say can increase your life expectancy by two years. Sleeping well, of course, without the help of any sleeping pill. Hopefully seven to eight hours a day. Not smoking. Zero smoking. Moderate alcohol intake. Moderate wine intake or beer or alcohol intake is allowable. And in fact, more people live longer if they take a little bit of alcohol at the time. Of course, we do not want to encourage anyone who has never taken alcohol to start drinking beer or wine just to increase their life expectancy. That's not what we recommend. More education. Keep on studying, learning, learn new things, new skills, meet new people, visit new places. Have a goal. Have a goal in life. Know who you are and what you can contribute to society. I have a very simple question. Mahilig akong kumain ng gulay, pero mahilig din ako magsigar. But because I'm a farmer, address ko na yung healthy lifestyle by being active the whole day and I eat vegetable. So the risk of having high cholesterol might be lower. Simple Filipino asking you, doctora, vulnerable ba ako dyan sa disorder na yan? Dahil karamihan ng ilukano, maabot ng 80, 90, malakos pa rin sila. Pero naninigariliyo, nag-sigar sila. What can you say, doctora? I think more ilukanos do not use tobacco. I think it's a misconception that just because you're ilukano you smoke tobacco. My grandparents from my father's side are ilukanos. They live to be 90 something. But they never smoke. They love to eat bagnet and things made from pork and fried pork. But they ate a lot of ang palaya, in the pinapet. If you look at the benefits of smoking cessation, the benefit is there.  So the risk of cancers, chronic obstructive pulmonary disease, heart disease, et cetera, from smoking is quite well though. So I would still recommend smoking cessation anytime. And many of those who live long have actually not smoked. There are epidemiological studies, for example, on blue zones, areas in the world where people live to be 100-year-old. And these people really live active, healthy lifestyles. A mixture of vegetables, a little bit of wine, a lot of physical activity. Being part and active at community or family. So these are some of the main points that contribute to their healthy life expectancy. Because you don't just want to live long, you want to live healthy. May I ask, doctora? I'm very impressed by the Philippine General Hospital program. Philippine General Hospital is the only hospital giving this program? For memory. There are a lot of centers for memory, mostly in private hospitals. Government hospital. Only PGA? There are some in some government hospitals. If one wants to consult with you, how do they... Oh, they can just go? They can visit there? Do you have special arrangement? They need to be referred by physicians? What is your... We actually have an email ad and I get questions from physicians in the province because I lecture a lot from the north to the south and then I get a lot of questions and most of the patients cannot travel to Manila. So I guide some of the physicians on how to handle their patients or how to even diagnose them. So that is a service that we provide. Is it expensive? No, actually it's a free service that we provide. In Philippine General Hospital, we see both service patients and private patients. And we even do memory tests and diagnostics to screen them because proper diagnostic is important. You have to have a proper diagnosis for you to be able to give the proper medication. There are many types of dementia. The usual will be Alzheimer's disease but there is also dementia because a person had a stroke or a person had traumatic brain injury from accidents and we get that a lot. Or sometimes they've had brain surgery or they have other diseases, other dementias from Parkinson's disease or from Lewy body disease. So the medication varies. So we have to identify the proper type. So how is PGH providing this education and promotion? How do we advise the public? How do we advise the public? So we only activated the center recently. Now we're on the data gathering stage. We're trying to get all of the patients to be screened, properly screened and also we do the memory screening. We do lay forums lay fora every now and then so to disseminate information. We also liais with Alzheimer's disease association of the Philippines and we have gone to many provinces. We have trained physicians, nurses and barangay health workers in recognizing people with dementia and how they should be able to consult and the treatment is available, symptomatic treatment. The Department of Health has this kind of program too? I am not aware currently if there is any active problem. Dr. Shelley. The WHO has a mental health MHGAP. They have a training system called MHGAP that came from the WHO. It's now at the level of the barangay health worker and they train barangay health workers on mental health issues which includes dementia but not to the extent of being able to screen at the level of the community. So I think the work that Dr. Anlakan mentioned which includes work from her group in PCH Alzheimer's association also augments this community-based awareness and even screening. So we have community-based? MHGAP, yes is already ongoing. Of course I'm not a spokesperson from the DOH, I'm from the NIH but I am able to meet with them on a regular basis for their programs. What we have recently signed by Secretary Ubyal is the guidelines for the implementation of the primary essential health care packages for all life stages from pregnant to the senior citizens and included in that package which is now an outpatient service delivery package is screening for problems of older persons including screening for memory problems at the community level but of course that needs to be supported by higher level services because if we are able to screen a person for example in the community who has frailty beginning dementia, risk of falling then there has to be someone in the secondary or tertiary levels in the hospital, specialists included who will be able to diagnose completely and manage these patients better. Officially I have a anybody can answer but I see a lot of old people doing crossword puzzles and I and I've asked this from my uncles and aunties they say they just want their mind to be working so and now that Sudoko has come out it's also one that's been popular do they help? And we also have some computer based gains right for maybe I can ask Dr. Anlakan to shed more light on this is it better to mental exercises physical exercise to prevent dementia or cognitive stimulation is always good one of the biggest risk factors for dementia is actually lesser number of years in school lesser number of years in school because the thinking is that the more you learn especially informal education and the more you have lifelong learning like you are open to anything that is new whether it be crossword puzzle or Sudoko or reading it builds up what we call cognitive reserve cognitive reserve are pathways in our brain or in our neurons connect it's like a tree that is very shady with all the branches so this cognitive reserve is something that you build up over the years and if you have very good cognitive reserve when you are already in your relatively elder age then it is something you can fall back on because if you start having the abnormal protein accumulation of Alzheimer's disease you can be relatively resilient meaning you may not have dementia because you built up a very good cognitive network earlier on so any lifelong learning is actually advisable it's never too late to learn anything and I always tell this to my patients especially those who are afraid of gadgets and appliances so I tell them you should try it you should give it a try always learn if you only have time now to learn the violin or to learn how to sing them do it but also physical activity is very important not just for memory but also for maintaining healthy aging anything that improves blood circulation will also prevent dementia so we need to keep moving physical inactivity is one of the risk factors we have international statistics as to what will give us dementia so if we try to reverse it if you look at them then you can prevent dementia number one is the number of years of education so the longer you stay in school the more protected you are and in midlife which is around 45 to 65 years old there are surprises actually avoidance of hypertension or controlling hypertension is a big thing aside from that avoidance of obesity and hearing loss so if you try to correct hearing loss in midlife you may be able to prevent dementia the theory being that if you are shut off from the rest of the world then there is no learning so your cognitive reserve just declines and declines in the later life there are more risk factors for smoking we will have more dementia because of smoking depression if you are socially isolated you don't have a lot of network of friends or family or if you have diabetes then yes these are risk factors for dementia but there are also clinical trials that help elucidate the benefit of physical activity and a multifactorial intervention that was done in Finland I think it's called a finger study so it was a combination of not just healthy diet but physical exercise, intellectual stimulation they did it in such a way that showed that really all of these factors that Dr. Anlakhan mentioned contribute to preventing dementia and improving longer functional ability when it comes to memory and NIH in the U.S. also did a study on physical activity that showed the benefit of physical exercise of course there are some studies that showed that it doesn't affect memory at all but I think physical activity in general will not only improve the circulation of brain but also overall health how is the Philippines compared to other Southeast Asian countries as far as these figures are concerned I would think that Japan is more developed and they take care of the old senior citizens I can see the programs when I was there and the Chinese people are very hard working up to 85 they still carry this sack of corn and they carry it if you pass by the railroad of China 85 years old they are still physically active is sedentary life related to early onset of dementia Filipinos are quite sedentary am I correct relatively yes I think the life expectancy of the Filipino including the healthy life expectancy of the Filipino has improved through the years because when I was still in med school my life expectancy was only about 60-65 now it's 67 and 73 mas lugay ng konte ang lalaki but I think when you look at the global aging index because there is an aging index and whether countries are advanced in helping promote healthy aging I think the Philippines still has a lot to achieve and the laws that protect our senior citizens we have a very good Philippine plan of action for senior citizens that includes 20% discount hopefully there will be some geriatric services and wards in all hospitals but the implementation of this law still has to be has to be accomplished well the social pension is one of the things that we are interested on and we just started giving the social pension of about 500 pesos per month to our very indigent older people of course we wanted to be a little bit higher than that and for more people rights of older persons I think the Philippines in terms of protection from from elder abuse still has to be improved because we still do not have a good organized system for addressing the abused older person but we are also rated with regards to our life expectancy and we have improved but compared to other Asian countries we lag behind Japan we lag behind Singapore we are more or less at par with other Asian countries like Vietnam Myanmar Cambodia remember that for middle income countries such as the Philippines and low middle income countries when we say life expectancy really are talking about maternal and child health reduction in maternal and child mortality is the key to improving life expectancy if we are very well developed such as countries in Europe Singapore and Japan what determines life expectancy is the services healthcare systems that are provided to the adults and middle aged which addresses problems such as hypertension, diabetes, stroke lifestyle diseases I like to ask both of you Chancellor Doctora Doctora we are so much influenced by my advertisement in the television and such claim like taking this herbal product will improve our memory this might give a different signal to the Filipino people and they will be encouraged buying this herbal product to prevent senility for example especially packaged by and marketed by very prominent people beautiful actresses an aging actress in the 60s taking the herbal product can you say something about the effect of this you go first I always get that question a lot unfortunately I think it's human nature to look for shortcuts or things that are beyond within their power they think they are vitamin deficient so they think that they need a lot of vitamin supplementation but actually it's very rare vitamin supplementation may not really be needed only on certain cases and for those really diagnosed to have the deficiencies they don't want to hear about having to exercise or having to eat more vegetables than meat or stopping smoking and avoidance of alcohol large amounts of alcohol they don't want to hear that they want shortcuts pills that they can pop every day to try and prevent if you look at all the advertisements most of them are targeted towards the people who don't have disease at all they are relatively healthy so of course they will say I'm not getting sick but because they're still relatively healthy but unfortunately the studies that support these supplements are very small and that's not how we do data analysis in the university and this is not for policy making also we need stronger evidence than that what we do have are medications for symptomatic improvement if you already have the dementia and it is specific to what type of dementia you have so it's very important that consultation is made that's enlightening were you tempted also to buy some supplements no I love to swim and that's my that's the source of my energy I love to swim so we hear dementia and simility so can you just explain it again to the viewers when you say your senile your what does that really mean ulyanin is that ulyanin yes in the Filipino language it is ulyanin usually we call our elderly people ulyanin if they are very repetitive or they cannot pronounce your name or they cannot recognize you anymore unfortunately we still lag in the awareness level even some of the doctors that I lectured to in the province for aging people to have memory decline but it is not normal I often say it is common but it is not normal it is a disease so this is memory decline that impairs our daily activities already so do we have numbers do we have statistics to tell us what percentage of our population the right statistics I think we have some based on the Delphi technique there was a researcher from the WHO he went around but mostly specialist reports of how many they have seen so this really are selected practitioners and they say that for the general population those with dementia amounts to between 2% to 6% but we don't have a registry 2% to 6% among in the general population but the percentage of dementia increases as people age and Dr. Anlakan can explain that because that is just a general trend that we talk about but we don't have a registry of persons with dementia we would like to have a registry of persons diagnosed with dementia just as I'm sure oncologists would like to have a cancer registry the international data will say that above 65 years old 65 to 70 we have 5% chance of getting dementia and above 85 years old it's approaching 40 to 50% so again it's very common but it is not normal so sometimes I also see a disparity as to when they consult the lower socioeconomic levels will consult when they are already having behavioral problems like the elderly patient would not eat or is very violent or not sleeping or not eating so those are the issues that bring them to the doctor but the relatively high socioeconomic levels those with higher education will come to you when they feel that they already have a memory decline or they are only missing certain things so that early prognosis is always good when they come early because medications work in the early stages in the latter stages unfortunately we can only give medications for better behavior later meaning 65 years old and above later stage of the disease meaning later stage of the disease they have to be assisted already in their everyday activities somebody has to keep track of their medications somebody has to remind them to bathe and sometimes they have to be bathed and dressed appropriately because of course this is because of a memory problem because sometimes they are frail or they are very weak or they have physical disabilities due to arthritis or they shake because of Parkinson's disease or they have hemiplegia they have paralysis due to stroke but these ones are really purely because of a memory problem but remember that there is no cure for dementia it's a little bit confusing about this study that was presented in congress claiming a health research by group of scientists trying to identify the toxin of spiders to cure dementia and I was listening intently and a congressman doctor asked are you sure that is a cure for dementia? cure for dementia it can only reduce the rate at which a person deteriorates but eventually the person will go through all the stages until the person is very dependent on all activities so there is nothing to reverse the condition the reason we give them medications is we want them to be able to hold on to what they can do so if at the moment they can still eat by themselves and bathe themselves then they can hold on to that longer with medication and also the behavior is they are more amiable they are easier to care for if they have medication but that is only as far as we can give what medication for example? we have colonist race inhibitors for memory so those are dunepazil, revastimin and galantamin and we also have NMDA receptor antagonists like memandi certain drugs that we give depends on the patient there is no single formula so we have to look at the patient and evaluate a patient individually and caregiver support is very important because sometimes it's the caregiver that needs more of our help than the patient what I'm getting is healthy lifestyle healthy aging and be active and to be as to be able to function the longest possible we really need more time to discuss the elderly and the aging but I'd like to request our resource speakers now to maybe give a message to our viewers we'll start with Dr. Shelley so in order to be healthy be functional throughout your lifespan do try to take care of yourself eat healthy be active physically be involved in community and with your family and make sure that you have a goal you know why you are here in this world because if you know why you are here and what you can contribute to the world then you will be able to age gracefully and be more healthy for as long as possible I think prevention is so much better than cure we should do everything in our power to try to prevent dementia via the risk factors and prevention strategies that we discussed earlier but also if you think you already have memory decline you should consult whether you are just not sure of yourself or you're doubting it because there might be other reasons why you are having it let us evaluate you and give you a proper diagnosis so you will be guided accordingly our discussion is really very interesting and we are glad that our audience is hearing this maybe for the first time but we have to say goodbye for now let us have the final message for our guests one word live healthy promote lifelong learning we will all face the inevitable in the future it is good that we understand the changes that will occur in our mind and body we should know what to do when we experience geriatric issues and senility I hope those who will care for the older persons have also benefited from this episode we hope that the families or households with older persons have listened to our resource persons so that we so that we can fully understand them and we know how to respond to their needs I hope you have found this episode relevant and live healthy and healthy