Senator Pinochet has a complex medical history, but the main active medical problems at present are diabetic peripheral neuropathy and recently progressive cerebrovascular brain damage. The diabetic neuropathology is contributing to difficulties in walking and to the observed tendency to postural hypertension. The diabetes will also have predisposed to arterial disease as will a past history of smoking The cerebrovascular disease has manifested partly as minor strokes and transient asthmatic attacks but also causes progressive damage without acute symptoms. There is clinical evidence of extensive damage to the brain.
This includes bilateral damage to pyramidal tracts to cause spasticity symptoms and to the basal ganglia producing features of parkinsonism. The presence of primitive reflexes indicates damage to the frontal lobes and the memory defecit is comparable with bilateral damage to temporal lobe structures. Difficulties in comprehension are secondary to the memory deficit. While much of the damage is attributable to areas of the brain served by the basilar artery (shown to be calcified, in the CT scans) the frontal lobe impairment indicates more generalised arterial disease.
Fitness for trial Physically: Senator Pinochet would at present be able to attend a trial but as features of cerebrovascular damage have progressed despite optimal treatment (with good control of diabetes and blood pressure and antiplaseler agents) further deterioration in both physical and mental condition is likely. Mentally: It is our view that Senator Pinochet would not at the present be mentally capable of meaningful participation in a trial. We base this opinion on: 1. Memory defecit for both recent and remote events.
Limited ability to understand complex sentences and questions owing to memory impairment and consequent inability to process verbal information appropriately. 3. Impaired ability to express himself audibly, succinctly and relevantly. 4. Easy fatiguability With these impediments he would be unable to follow the progress of a trial sufficiently to instruct counsel. He would have difficulty in understanding the content and implications of questions put to him and would have inadequate insight into his difficulty. His memory of remote events is impaired.
He would have difficulty making himself heard and understood in replying to questions. We are satisfied that the impediments we have identified are due to brain damage, as they are coherent in nature and consistent in manifestation and formal neuropsychological testing showed none of the features of deliberate exaggeration of impairment. In particular those neuropsychological tests indicative of original intelligence and educational levels (such as the vocabulary scale of the WAIS)show superior performance. At present, Senator Pinochet shows no evidence of clinical depression.
Situational stress, as likely to be occasioned by trial, produces physiological responses that could accelerate the progression of vascular disease. We were told, however, that Senator Pinochet has in the past shown notable personal abilities in managing stress. We therefore do not feel able to express any useful opinion on the possible effects on his health of undergoing trial. The major episodes of damage seem to have occurred in a cluster of thromboembolic events during September and October 1999. There has been sufficient time for the great majority of any expected spontaneous recovery from these events to have taken place.
Although some day to day fluctuation in functional abilities is characteristic of brain damage due to cerebrovascular disease we consider further sustained functional improvement of a significant degree unlikely. Background – the rest of the report: Professor Sir John Grimley Evans, Dr M J Denham, and Professor Andrew Lees undertook a clinical consultation with Senator Pinochet at Norwick Park Hospital on January 25th 2000. The consultation was undertaken in Spanish. Also present: Dr Henry Olivi (Observer) Prof. D J Thomas (Observer) Nurse Shelley Cape, Manuel Cerda (Senator Pinochet’s valet)
Recent Medical History: Following surgical decompression of lumber spine in 1998 Senator Pinochet was troubled for some weeks by severe headache across the brow. This resolved spontaneously. For the last 8 to 9 months he has noted difficulty in walking and now can only cover 200 yards before his legs become too weak to continue. He now walks with a stick. Numbness of the soles of his feet has also progressed over that time. Over the last ten months he has noticed a gradual progression of problems with memory which have become much more marked recently.
He has difficulty in remembering people’s names and in recalling dates and events of long ago. Has been reported as talking as if he had difficulty in turning ideas into speech. On September 9th 1999 Senator Pinochet was walking in the garden and developed a sudden headache and imbalance. Other episodes suggestive of transient cerebral dysfunction reported to us include once failing to recognise his wife and once failing to register that his son had visited him. He also recalls an episode in which his vision became dim for a short period.
When seen by Dr Thomas on September 14th Senator Pinochet showed nominal dysphasia and circumlocution together with a positive glabellar tab, blank facies, pour reflex and brisk jaw jerk. Gait was small stepped with instability on turning. The Romberg test was positive. Left-sided upper motor neuron weakness worse in leg than arm was noted as was short-term memory defect. The clinical diagnosis was of multiple small bilateral cerebral infarcts. When reviewed later by Dr Thomas (letter 13. 10. 99) further deterioration with probable further cerebral ischaemic events on September 20th and October 9th.
A definite increase in parkensonian features was noted, with parkensonian speech difficulty, deterioration in handwriting, inability to dress himself, and needing help with rising from chair and with transfers. Since then the senator has had two further falls, one in the garden and one in the bathroom, both due to loss of balance without impairment of consciousness. His voice noted as quiet in October has also deteriorated. There is a history or urinary symptoms – hesitancy, poor stream, urgency and occasional minor incontinence.
He can generally stay in bed until early morning but thereafter may have to void 3 or 4 times. Senator Pinochet was depressed last summer but following a change of therapy… this has ceased to be a problem. He still feels homesick and bored and frustrated by his physical ills. He wakes frequently at night. In recent months he has lost interest in former activities. He used to read and use the computer but now tends to sit watching television and says he has forgotten how to use the computer. Letter writing has become a chore and his handwriting less legible.
Recently he has developed difficulty in shaving without cutting himself. His appetite is unremarkable, weight steady recently following temporary loss during last year. He has been troubled in recent months with aching pain in both buttocks, and his knees hurt in cold weather. Postural hypotension has been recorded in the past, but this has improved since reduction in dosage of terazosin and stopping amlodipine (Dr Olivi). Current Medication: Budesonide 400 ug b. d. Merformin 500 mg t. d. s. Finasteride 5 mg daily Nimodipine 30 mg b. d. Allopurinol 150 mg daily Amiodarone 200 mg daily Thyroxine 75 ug daily Terazosin 2. mg daily Citalopram 30 mg daily Clopidogrel 75 mg daily Terbutaline inhalation p. r. n Examination: Senator Pinochet arrived in a wheelchair and was interviewed in bed. He is severely deaf but able to conduct conversation when his hearing aid in place. He was alert and co-operative but easily tired. His voice was quiet and monotonous in tone and speech was indistinct. There was no abnormal lymphadenopathy. A well-healed lumbar laminectomy scar was noted Cardiovascular system: Pulse 65 regular (pacemaker in situ). No oedema, normal jugular venous pulse. Cardiac apex not palpable. Heart sounds normal.
No carotid or abdominal bruits. Femoral and dorsalis pedis pulses present on both sides, posterior tibial pulses not palpable. Blood pressure 135/70 lying and standing on one occasion. 130/60 lying changing to 110/70 standing on another (associated with some unsteadiness). Chest: Pacemaker in situ in left upper chest, no other abnormality detected. Abdomen: Obese. Normal to inspection, no tenderness or guarding. Liver, spleen, kidneys and bladder not palpable. No abnormal masses. Nervous System: Cerebration: Showed slowness in comprehension with difficulty in understanding complex instructions.
Showed bradyphrenia and circumlocutory speech but no lower level dysphasia. Mini Mental Status Examination score 23/30. Mood: Good rapport and cooperative. Face immobile but smiled appropriately. Sense of humour intact. No evidence of depression. Gait: Required help getting out of bed and in steadying when standing. Wide-based short paced gait holding stick in right hand and no swinging of left arm. Tendency to fall backwards. Turning unremarkable. Romberg – some swaying but did not fall. Handwriting: tendency to micrographia Primitive reflexes: Pour reflex present.
Palmomental positive bilaterally left more than right. Jaw jerk normal. Glabellar tap positive. Cranial Nerves: I – Intact, but unable to name scents II – Fields full to confrontation, discs normal and no retinopathy III, IV, VI – External eye movement full, no impairment of upward gaze, no nystagmus. Pupils small symmetrical react to light. V – Motor and sensory function intact all three divisions VII – Full facial movements VIII – Perceptive type deafness both ears, left worse than right IX, X – Palate move normally mid line. Gag not tested XI – Intact XII – No fasciculation of tongue.
Movements full in extent but reduced rapidity of sideways movements Upper Limbs: Appearance normal, no tremor, no fasciculation. Tone increased bilaterally with cogwheeling bilaterally but more prominent on right. Some drift of left arm on extension. Power normal. Coordination difficult to interpret owing to patient’s difficulty in understanding requirements. Possible subjective dulling of pinprick sensation distally but no impairment of light touch proprioception or vibration sense. Reflexes normal and symmetrical. Lower Limbs: Some fasciculation in both calves.
Movement poor owing to painful joints. Tone increases bilaterally. Power symmetrical and good. Coordination normal on right, some impairment in left. Loss of light touch and pinprick sensation in stocking distribution to mid-calf level. Proprioception impaired in toes. Vibration sensation absent from knees downwards, knee jerks present on reinforcement on right, unobtainable on left. Ankle jerks absent. Plantar responses extensor bilaterally. Investigations: ACG showed consistent pacing at 65 beats per minute; further interpretation not possible owing to pacemaker artefact.
Pacemaker electronically checked and found to be fully functional. CT scan of brain basilar artery calcification, moderate generalized atrophy with evidence of lacunar infarcts. NO significant change from previous scan. (MRI not possible owing to presence of pacemaker). Haemoglobin and blood picture, urea and electrolytes (including calcium) normal. Neuropsychological assessment: Undertaken in Spanish by Dr Maria A. Wyke, Devonshire Hospital, London. Tests included Spanish version of WAIS, Coloured Progressive Matrices, memory tests for designs, short story, pictured objects and Spanish version or paired associates.
Summary Report: General Pinochet shows a moderate/severe deterioration of intellectual function beyond that due to his age. He was a person of superior intelligence and at present is functioning within the low average/average range. Short term memory, learning ability and delayed recall all show severe deficit. His greatest difficulty is his inability to retain information over time. There is no evidence that General Pinochet is attempting to fake disability. In my opinion he would not be able to cope with the legal complexities of a trial.