026: Expert Insights About Cognitive Issues – Dr. Dana Chidekel

Marty Stevens-Heebner
When you think you see the early signs of dementia in a loved one, who do you turn to be sure? A doctor, of course. But what kind of doctor do you want to turn to? If you've never heard of a neuropsychologist before? And even if you have, you definitely want to hear from our expert on this episode.
Moving your mom or your dad or yourself isn't just about moving things from one place to another. It is much more complicated than that. As are so many things having to do with later life. How to Move Your Mom (and still be on speaking terms afterward) provides in-depth conversations with professionals, older adults, and their family members who share their stories with warmth, understanding, and humor.
I'm your host, Marty Stevens-Heebner and here you'll find answers to many of your questions as well as different perspectives that I hope will inform and inspire you.
I am so lucky today to have with me Dr. Dana Chidekel, who's a brilliant neuropsychologist. Thank you so much for taking the time to be here, Dana.

Dr. Dana Chidekel
Oh, Marty, I'm so glad to be here with you. This is a lot of fun me.

Marty Stevens-Heebner
Let me tell you a bit more about Dr. Dana. Dr. Dana Chidekel is a clinical and forensic neuropsychologist double board certified by the American Board of Pediatric Neuropsychology and the American Board of Professional Neuropsychology. Dr. Dana evaluates children and adults aged four to 102 referred for cognitive, developmental, academic and psychiatric problems. She's also retained as an expert witness in many types of cases, including probate and estate planning, which really applies to what we talk about on our podcast. Dr. Dana is the author of Parents in Charge: Setting Healthy Loving Boundaries for You and Your Child. She's also appeared multiple times in the Today show. Very impressive.

Dr. Dana Chidekel
Life is long.

Marty Stevens-Heebner
Life is long. Yes. Yes. So what's your favorite memory of your grandparents?

Dr. Dana Chidekel
My grandparents lived back east. We were in California. And my grandmother would come out, and she would have individual baggies that she'd closed with rubber bands. And she'd have them in a bag. We'd sit in the backseat because we were driving from the airport, and she would, with great ceremony, take each thing out, and we were on tenter hooks, and little things like animal crackers or a little thing she'd cut out from the family circus. But then we also had songs. It's fun that this is video, as well as audio, so I just got to do it for you because my grandmother was a very kind of jazzy, snazzy person in a conservative shell. So if it was time to sing Mr. Moon. So she'd say, "Oh, Mr. Moon, right at silver moon, won't you please shine down on me?"

Marty Stevens-Heebner
Oh, I love that.

Dr. Dana Chidekel
It's a shame we don't get to spend more time with our grandparents as we get older and get to ask them all sorts of questions when you can see them in a wider way.

Marty Stevens-Heebner
That is a shame. I think of even just my parents. Every so often, I think of something, okay, mom would know that. Can't ask her anymore.

Dr. Dana Chidekel
Right.

Marty Stevens-Heebner
So let us talk about the focus of your work. What exactly is neuropsychology?

Dr. Dana Chidekel
So neuropsychology is... You have to be a clinical psychologist, and then do two more years of training to understand the relationship between brain functioning and behavior. My job is to understand what's causing the behavior that I see. So I say it's when people call me, presuming we're not talking about the post-death determination of capacity or influence in somebody I can no longer see, but when somebody comes in, I say, "This is a math problem, and you're coming to me with the answer on the other side of the equal sign. Here's what we see. Here's what we tried. This happened last week." What you don't have is the equation, why is this happening? A neuropsychological evaluation, tests that I give are designed to understand what it is that's driving what you see in order to figure out what to do to make it better. You had mentioned dementia. A lot of times as people get older, certainly as we are all aging and you have these kind of normal lapses, and then the question sometimes becomes, well, it seems to me more than normal, or is it?

And then another question is, a lot of times depression presents like dementia does, and making the differentiation between those is critical in terms of figuring out how to move forward in the ways that are going to be helpful.

Marty Stevens-Heebner
That's a wonderful explanation. Thank you for that. So what's normal forgetting versus more like dementia forgetting.

Dr. Dana Chidekel
Normal forgetting, well, we all do it. It doesn't get in the way of our functioning, and it doesn't put us or anybody else in danger. Early signs of dementia don't necessarily put anybody in danger, but they start to get in the way of functioning and things. I think you have to also understand that for each person, they have a baseline of who they were. I knew someone who was the head of cardiology for a major teaching hospital, and he began to become demented, and his long-term care insurance company denied him. They sent him for an evaluation, and he scored in the average range in a variety of areas. Even before I did my evaluation, I said, "This is the head of the cardiology department. You think he's average? You think this represents okay functioning?" So it was clearly a sign that he was losing his capacities. So it's all relative to the person. And then the way that we think about intervening is when we start seeing it getting in the way of taking care of yourself, or on the other side, also maybe harming others.

Marty Stevens-Heebner
You'd mentioned that depression can sometimes look like dementia. Can you talk about that a little more?

Dr. Dana Chidekel
People who are depressed, they're forgetful, they may not take care of their hygiene. They're withdrawn socially. They can look like people who are becoming demented. One of the critical differences, and one of the things you look for when you're testing is really how good is memory? When we talk about memory, it's not just one thing. What can this person remember? How much can you initially take in? How much of what you took in can you what we call retrieve spontaneously? Like if I say, "What were those words I just read to you?" But then if I said, "Was this a word that I said to you? Was this a word?" sometimes people go, "Oh yeah." So it's in there, and it was a matter of how it got filed that's an issue. You can see problems with the organization of things, but when you start actually losing information or it never gets encoded to begin with, that's more a sign of dementia.

Marty Stevens-Heebner
That's the neuro part of neuropsychology.

Dr. Dana Chidekel
It is, and to understand the brain systems that are involved in different kinds of dementing illnesses. I'm a little bit of a concrete thinker. Things have to make sense to me. If something doesn't make sense, it makes me worry. My first specialization is in pediatric neuropsychology because you have to understand what is it that develops, that lets us go from being utterly dependent to then being able to take things over on our own. So when you look at neurodevelopment, and then on the other side of life, sometimes neurodegeneration, there are certain capacities that we lose. So understanding what it was to begin with is so important.

For example, here are four things that are developing very dynamically through childhood, and they are the ability to initiate action to purposefully set yourself in motion to something you need to do, the ability to not act, which is inhibition, the breaking system, the ability to keep something going once you've started it, so you get to your goals, and the ability not to keep something going once you've started it so you don't get rigidly fixated on something that no longer is what you really need to do. When you think of little itty bitty kids, they aren't developed in this. We don't say, "Okay, when you get to the street, stop.' We hold their hands. We are the breaking system. We say, "Now it's time to brush your teeth. Now it's time to put on your socks."

We are supporting all of those capacities as they're developing. "Oh, look at this. We were going to go on a picnic, but it's raining. We're going to make a different plan." That kind of shifting. As those things develop, they allow us to then take over responsibility for life on our own. If you look at components of what we lose, the ability to know, oh, I've got to call the doctor, or go to the appointment, or take my medicine, it's a more childlike way of being. Impulse control can go. That can make people who need a lot of help very difficult to help because they can get very cantankerous. And they can get paranoid because they know something's wrong and they don't have the insight to say, "Wait, this is me," because that's part of what goes. You can see that there's no breaking system, that people get rigid. They can't understand bigger ideas, so you look and see what is it that people are losing that makes them more dependent on others.

Marty Stevens-Heebner
Years ago, we were working in a home. We were helping the son, who was the executor, clear out the home. I was working on the desk. And I opened the desk drawer, and it was filled with the check boxes that checks come in. And remember, they used to send all the checks back? I opened one of the boxes, and there was this pristine wallet. It was a men's wallet, [inaudible 00:08:55] bills in it, new credit cards, except they had expired years ago. I took it to Tom, and I said, "I found this." And he goes, "Oh, the wallet." It was a family story. His mother had started to exhibit signs of dementia. And his father had come home, really tired from work, and sat down. And they had a little bar there, so he'd left his wallet and probably his car keys on top of the bar. He had his eyes closed. He heard his wife come in and go. When he stood up just seconds later, the wallet was gone. So he went to find his wife and he asked her where it was, and she could not remember.

Dr. Dana Chidekel
Oh wow.

Marty Stevens-Heebner
I think part of the story is that was a huge indication that her dementia was worsening substantially. She just couldn't remember within the space of about 30 seconds. But here's the thing that I said to Tom. I said, what's fascinating is that she had tucked it away in the drawer with all the canceled checks. So she thought it was unsafe, the wallet.

Dr. Dana Chidekel
Right. Right.

Marty Stevens-Heebner
And took it and put it in with the other stored items that had to do with money.

Dr. Dana Chidekel
There's a relationship there. It makes a certain kind of sense.

Marty Stevens-Heebner
That was so interesting. And that was a tough story for them to live through, very tough story.

Dr. Dana Chidekel
I'm also thinking with my forensic hat. What were the dates on the credit cards? You can really start to look at how somebody's functioning when you look for clues like that.

Marty Stevens-Heebner
What are the benefits of a neuropsychological exam for older adults?

Dr. Dana Chidekel
The reasons people do it is when they have questions. You've been noticing your parent is more forgetful or something. You've already found something, which is why you're calling me. And the question is, what's the source of it? An evaluation is, first and foremost, a kind of therapeutic tool to give people a way of thinking about the things that they're seeing in themselves or others. When there's a problem, our brains like to make sense of things. Let's think about this ability to inhibit behavior, put on the brakes. That is a critical thing in terms of... Little kids can't use thinking to guide their behavior before this develops. They just act, right? Squirrel. So as we can stop ourselves, we can think about what we're doing. Well, as that diminishes, we can't think. We just act in response to what's in front of us. The wallet's missing. You're here, you did it, and your brain wants to make sense of it.

Helping people to understand this isn't your mother trying to make you crazy. This is really something you can have empathy for because she is struggling in a world that doesn't make sense, and she is doing what everyone's brain does, which is trying to make sense of a situation so it's resolved, because otherwise your brain kind of keeps chewing on it. And brains don't like to do that. Brains are like, I've got a lot to do. Put this away so I can keep doing the things that I need to do.

Marty Stevens-Heebner
Like keeping you breathing and keeping your heart beating.

Dr. Dana Chidekel
Keeping you breathing, keeping your heart beating, keeping you alert for dangers in your environment? On the Savanna, where did I put the club? Wait a second, I had a torch that I was going to use fire, and I think I put it here. And then the saber-toothed titer comes and takes you out because your brain was occupied with some kind of repetitive thought or distraction, as neuropsychologists... If fundamentally your brain is about survival, how do we make sense of all these fancy terms and ideas in terms of what those would've looked like in more primitive times?

Marty Stevens-Heebner
Yes, and they didn't have a phone screen that they were staring at or going through photos on it Yes.

Dr. Dana Chidekel
Who was happier before we had answering machines? It's seductive. There's that feeling of there's just more and more and more and more, but it doesn't feel good. There's a wonderful author, Peter Whybrow. I think he was the head of the Semel Institute at UCLA. He's a psychiatrist. And he wrote a book called American Mania: When More is Not Enough. And it is incredibly readable and it talks about the way we live in our society, goes into the genetics of it, and it's like a manic episode. If you've ever seen a patient who has a bipolar disorder or is it a manic state, it's this inquisitive thing that feels great. But then it doesn't feel great, and they can't stop. And they get irritated and agitated, but you keep going and keep going. So he talks about this state of being like a manic state that we're in. It doesn't feel good, but it doesn't let go.

Marty Stevens-Heebner
It does feel like that. And COVID didn't help matters.

Dr. Dana Chidekel
Oh God.

Marty Stevens-Heebner
That's a whole other episode.

Dr. Dana Chidekel
One of my mentors said, if you are a competent neuropsychologist, you should be able to conduct the entire evaluation with a ball and a stick. And I had the extension to do something like that. It was not a ball and a stick. It was a plate of cookies in advance of a social event that I was arranging with an elderly person. And I'd say, "Joan, make yours look like mine." And we did this whole evaluation. I was able to definitely assess that she was having a lot of cognitive problems based upon watching how she was doing things. She would get the brownies and she pinched them, and she couldn't stop. And that's a symptom of your breaking system that doesn't work. It's called stimulus boundedness. There's a stimulus and you're bound to it. You can't stop yourself from responding. So every time she'd pick up a brownie, she'd pinch it. And I'd say, "Joan, okay, don't pinch them," and she couldn't help herself. It was amazing.

So the authority behind a neuropsychological test isn't in the test itself. It's an understanding what the findings mean. You have to think about what it is that they're measuring and how to watch how someone gets to the scores that they do. But I think it's important for my field, that we practice at a certain level, and that we represent the field in a way that has a certain kind of standard.

Marty Stevens-Heebner
Dr. Dana, what distinguishes your practice from others?

Dr. Dana Chidekel
I am board certified. And if you're working with somebody, you should make sure that they're board certified. It does mean that you met a certain standard of education and that you passed a certain standard of knowledge with respect to the material of your field.

Marty Stevens-Heebner
I have to mention you're double board certified.

Dr. Dana Chidekel
Yes.

Marty Stevens-Heebner
Very impressive.

Dr. Dana Chidekel
Thank you. Part of that is wanting to test myself and say, have I mastered this? It is based on my need to have things make sense, to understand neurodevelopment and neurodegeneration. I can be a kind of concrete thinker and certain things are very hard for me to understand, and I've never been able to kid myself if I don't understand something. I need to understand things in a way that I can explain them in common sense terms. I take complicated ideas and explain them in simple ways, and I do that whether I've done a clinical evaluation and I'm now meeting with the people to talk about the findings of that. It turns out to be a wonderful skill to have as a expert witness because your whole job is to teach people, to say, "Oh, okay, I took all this information and I looked at it, and here's what it is," and to be able to tell the story in simple, credible ways that people can follow.

So I think one of the things that distinguishes me is kind of a mission statement that my job is to explain these things in ways that are accessible to everyone. By definition, people who come for evaluations are anxious about something. Something is wrong. And for me to be able to deliver something that's tangible that people can understand and feel better, that doesn't increase their anxiety, but to make it something that's tangible that people can understand.

Marty Stevens-Heebner
It's so important because we've all been to doctors who talk in medical jargon, and you have to ask them to interpret it, and they can't necessarily do that. But I know, you've told me this, that you really love being a teacher.

Dr. Dana Chidekel
I love teaching. I think about my grandmother going back to that story, and what pleasure we got out of those little things. But now I know, and I'm getting chills as I say this, what pleasure she had in giving them to us, how special it was for her, right? Because it feels wonderful to give something and to have it received. Teaching is, okay, I'm going to understand this, and then I'm going to give it to you. So this is my job. This is why we're together, is you needed me to understand something. And now I've understood it, and I'm going to give it to you so you can have it. And then it makes the person feel better, hopefully. Sometimes in the short term, not so much, but it's such an amazing feeling for me. And I love that, whether it's in my professional practice or in something else that I do and understand and somebody else is interested in. I love sharing it and seeing that they have received it.

Marty Stevens-Heebner
It's almost even better for the giftor door than the giftee.

Dr. Dana Chidekel
If we all did one kind thing for each other during the day, simple thing, let someone in front of you when they're merging on the freeway, let them in front of you in the grocery line, that would shift so much, because it seems that things have gotten so primitive and everybody is looking out for what's going to happen like it's a dog eat dog thing. But if we then had in mind that we would be doing these things and we would notice when other people were doing them, the other part of this, for those who, okay, forget all that, you want to take control of a situation, do that. It's like-

Marty Stevens-Heebner
So true. Give somebody something.

Dr. Dana Chidekel
Give somebody something. Right. Let them in on the freeway. You have controlled that circumstance. But I think it would be such a wonderful shift in our world.

Marty Stevens-Heebner
I think it's important. I think I've told you this, that chronic depression runs in my family and I have it.

Dr. Dana Chidekel
Yes.

Marty Stevens-Heebner
And one of the things I'm proudest of is that I really dug in and learned how to manage it, how to deal with it. That took a lot of work. It was really hard, and it took years, but my life is really great now, and I'm so glad I did that work. You have to do the work.

Dr. Dana Chidekel
Yes.

Marty Stevens-Heebner
And it's interesting when you talked about depression and dementia, because I remember I was so caught up in my own depression when I was younger that I couldn't remember things. I couldn't think through things or comprehend them necessarily.

Dr. Dana Chidekel
Well, it's actually part of the diagnostic criteria for depression, kind of confused, difficulty making decisions. A lot of times, it goes along with sleeping problems that make everything worse. So if you just look at which check mark you have to check, there's a definite kind of Venn Diagram overlap, because essentially dementia is, you can't pay attention to the things you need to pay attention to and store them effectively.

Marty Stevens-Heebner
It's an interesting comparison, and an important one too, because they're very different diseases.

Dr. Dana Chidekel
And they need different treatments. There are conditions that are progressive that deteriorate, but depression is not one of those. Depression is transient. It's treatable. So that's a critical thing to understand in terms of not only what are we going to do for this person now, but also what are we thinking for this person in a year, in two years, in three years in the future? It is a progressive disease, unfortunately not curable.

Marty Stevens-Heebner
When I'm training staff, sometimes we have to talk to the relatives of someone who has dementia and just remind them it's the disease.

Dr. Dana Chidekel
Yes.

Marty Stevens-Heebner
They're not trying to drive you crazy.

Dr. Dana Chidekel
Right.

Marty Stevens-Heebner
It's the disease. They really don't remember that they've asked you the same question five times in the last 10 minutes.

Dr. Dana Chidekel
Right.

Marty Stevens-Heebner
They can't remember. Are there any risks associated with neuropsychological testing on people?

Dr. Dana Chidekel
It's not an invasive process. There is interviews, and then there's sitting at the table and having people put blocks together and trace paths on mazes. Sometimes there's computerized reaction time tests, but none of them are injecting anything into anybody's anywhere, in their veins or anywhere. You're not putting leads on their head. There's nothing that should be traumatizing. People say most of that was pretty interesting, and some of it was boring, but it's all interactional. Because as I said, I'm as interested in how people get to the scores they get as I am in the scores they get. For example, look at this picture of these red and white blocks. And now, here these blocks. I want you to make that. So let's say it's a two by two design, and you're allowed 75 seconds to do it.

Let's say the person does it accurately, but they took 90 seconds. Well, they would fail it. And let's say a person just stacks the blocks one on top of the other, doesn't even understand the thing, they also fail it. Or let's say somebody does it, but they make a mistake in the upper right hand corner, and that's an area they consistently make mistakes on in other ones, they'll fail it. All those people are getting scores of zero. But that's why I'm saying you can give these tests. You just have to understand all the information they give you in all of these kind of observations.

Marty Stevens-Heebner
It's not cookie cutter.

Dr. Dana Chidekel
Please let it not be cookie cutter any more than any of us are. These things, you can't give them by drive-through. It's an interactional experience, and you're looking at nuances. You're watching different qualities of behavior, qualities of movement. Is there a tremor? You're also understanding something about credibility. And it's most relevant in the forensic work that I do, people who have a vested interest in appearing more impaired or may have a vested interest in that. You have to understand what your case is and who your person is, and whether you can trust the numbers that you got. Because you can give a whole bunch of tests and you could score them, but if you also have evidence that doesn't really represent what they can do, then you just have a bunch of meaningless numbers. No one can fake good on a cognitive test. You can't do better than you can do, but you can definitely do worse than you can do. So if they're doing well in certain areas, they didn't fake that, it's the other ones that you don't know about.

Marty Stevens-Heebner
What questions should somebody ask when they're considering which neuropsychologists to work with?

Dr. Dana Chidekel
You can ask, what are they going to cover? And do they include psychological testing? And how important do they think that is? One of the things you want to understand is what somebody's philosophy is. And I think that there are questions to ask, but then there is your own subjective experience while you're talking to the person. Mine is a very kind of hands-on process. I feel like part of deciding to work with me and part of my decision about whether I want to work with somebody is needing to talk with them and explain to them what things are, and then get a sense of who they are and whether this is going to be a good match for my point of view as well. So you can ask about board certification, you can ask about philosophy. There are some neuropsychologists who think of themselves as very specialized in understanding cognitive functioning, and psychological part of it is not part of it.

That's not my practice. I'm very interested in understanding the interplay between how we think and how we feel, how things that we struggle with affect our emotional lives, and how our emotional lives affect what we can do. So it's a big picture.

Marty Stevens-Heebner
You were talking about all the observations that a good neuropsychologist needs to be able to make. You want somebody, I imagine, with a lot of empathy and who is just a great listener.

Dr. Dana Chidekel
You need somebody who's a great listener and a great observer, but you have to know what you're looking for. You have to know what's relevant, what's significant. Well, if somebody's limping, for example. You have to ask about it. Are you in any pain? How did you sleep last night? Does someone seem tired? Does it seem like after lunch, they're falling asleep? All of those things are important. There's an old urban legend about somebody who was being evaluated by a large research organization. To understand this story, you have to understand that your right hand is controlled by the left side of your brain and your left hand is controlled by the right side of your brain. So the person did just terribly on everything that was presented to her left hand, like pegs in a peg board, group strength. It was an unbelievable difference. And so the person concluded that this person must have a massive right hemisphere injury. The thing was the person's left hand was in a cast.

Marty Stevens-Heebner
Oh, come on.

Dr. Dana Chidekel
So you can't just say, "I'm a hammer. Everything looks like a nail." First, you got to rule out other stuff. If someone's limping, you're thinking, is that because of a brain problem, or is that gait because of something, oh, I recently had surgery, as opposed to it being an underlying kind of neurodegenerative problem? So you have to look at things, and then you have to know what to ask about and what's relevant. So it's a trained eye.

And the empathy part, I think you have to be interested in people and love your work. Be very open, and then also understand how to give bad news, because sometimes you have to give bad news. I think it frightens people to come for the assessment. I do evaluations if somebody is an older person who's making changes in an estate plan, and it is anticipated that someone who might be disadvantaged in the new plan is going to come later and say, "Oh, my dad didn't have capacity when he signed that and he was unduly influenced by my sister and everything." So I will sometimes get called in to do an evaluation, and this is usually for larger estates, that is at the same time that they're doing that signing to determine do they have the capacity, based on the legal standards, and are they being influenced?

But nobody who's referred for these kind of evaluations wants to come. Here you are, this person, you're aging, you're having this because you're at an age where this might be questioned. There's nothing for you to gain from this. The only thing is you might find out, yikes, aren't we all hoping we don't pull that card from the deck?

Marty Stevens-Heebner
Oh my goodness, yes. And the thing is though, what they do walk away with is a diagnosis.

Dr. Dana Chidekel
It's a diagnosis, and now that we know this, it also lets us say, here's what you can do now. Here's the ways you can prevent things from getting worse. Here's the measures you can take to protect yourself or your loved one. But even to come, I think it's so hard for people. Even when I'm evaluating kids for parents to pick up the phone, it's a decision to say, "Okay, I'll take the next step, and I'm afraid that there may be something to see." And sometimes it's exactly what you were afraid of, but then you can say, "Okay, we've opened it. Here's the monster in the closet." It's not whatever you thought it was as long as it's hidden, right? We can expose it and say, that's what the monster looks like. Let's make friends with the monster. This is how it behaves, and let's make some plans around that so you don't have to feel so helpless.

Marty Stevens-Heebner
If you got a big lump somewhere, that monster's not going to go away.

Dr. Dana Chidekel
It's like an uninvited guest everywhere. It frightens you all the time. It's always with you until you actually look and see what it is, but it's a very strong desire to keep things the same. This is my fear, this is how I live, but it's going to change things when you take a look at it. And brains don't like to change either because they know how to run the programs they're familiar with, and it lets them keep their brain eyes open for the saber-toothed tigers on the Savanna.

Marty Stevens-Heebner
And that's why the work you do is so important. Thank you so much, Dr. Dana, for being with me today. Such important information, and you talk about it so beautifully.

Dr. Dana Chidekel
Marty, I'm so appreciative of the opportunity to be here and talk to you, and honored that you would ask me. And I'm happy that we had a chance to do it.

Marty Stevens-Heebner
Me too. Thank you.
Marty Stevens-Heebner: Thank you so much for listening to How to Move Your Mom (and still be on speaking terms afterward). Please visit www.howtomoveyourmom.com for more information about this episode and for additional podcast episodes, featuring more extraordinary guests and conversations. Until next time, this is your very grateful host Marty Stevens-Heebner.