Citation Nr: 0111673 Decision Date: 04/23/01 Archive Date: 05/01/01 DOCKET NO. 99-12 968 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for Alzheimer's disease. 2. Entitlement to service connection for post-traumatic stress disorder (PTSD). 3. Entitlement to an increased evaluation for manic depressive psychosis, currently evaluated at 50 percent. REPRESENTATION Appellant represented by: South Carolina Department of Veterans Affairs ATTORNEY FOR THE BOARD R. M. Panarella INTRODUCTION The veteran served on active duty from June 1938 to November 1958 and was confined as a Prisoner of War (POW) of the German government. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the December 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office in Columbia, South Carolina (RO). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained. 2. Competent medical evidence relates the veteran's Alzheimer's disease to his period of active service. 3. The veteran has not been diagnosed with PTSD. 4. There are no current identifiable symptoms of manic depressive psychosis. CONCLUSIONS OF LAW 1. Alzheimer's disease was incurred in or aggravated by active service. Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000); 38 U.S.C.A. §§ 1101, 1110 (West 1991 & Supp. 2000); 38 C.F.R. §§ 3.102, 3.303 (2000). 2. PTSD was not incurred in or aggravated by active service. Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000); 38 U.S.C.A. §§ 1101, 1110 (West 1991 & Supp. 2000); 38 C.F.R. §§ 3.102, 3.303 (2000). 3. The criteria for an evaluation in excess of 50 percent for manic depressive psychosis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1-4.14, 4.130, Diagnostic Code 9432 (2000). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection As a preliminary matter, the Board notes that effective November 9, 2000, the Veterans Claims Assistance Act of 2000, was signed into law. See Pub. L. No. 106-475, 114 Stat. 2096 (2000) ("VCAA"). This law sets forth requirements for assisting a veteran in developing the facts pertinent to his claim. The Board finds that even though this law was enacted during the pendency of this appeal, and thus, has not been considered by the RO, there is no prejudice to the veteran in proceeding with this appeal. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (when the Board addresses a matter not addressed by the RO, the Board must provide an adequate statement of reasons and bases as to why there is no prejudice to the veteran). The Board finds that the veteran was provided adequate notice as to the evidence needed to substantiate his claims. Although the veteran was initially informed of the evidence needed to establish a "well-grounded" claim, which is no longer a valid basis for service connection, see VCAA, supra, the basic elements for establishing service connection, irrespective of the "well-grounded" doctrine, have remained unchanged. The RO has made satisfactory efforts to ensure that all relevant evidence has been associated with the claims file, and there are both private and VA medical records in the file. The veteran was afforded a VA examination in December 1998 and the Board also obtained the review and opinion of a medical expert. In short, the Board concludes that the duty to assist has been satisfied, as well as the duty to notify the veteran of the evidence needed to substantiate his claims, and the Board will proceed with appellate disposition on the merits. According to the law, service connection will be granted if it is shown that a veteran has a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease. 38 U.S.C.A. § 1110 (West 1991 & Supp. 2000); 38 C.F.R. § 3.303 (2000). Generally, to prove service connection, a claimant must submit (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Pond v. West, 12 Vet. App. 341, 346 (1999). Where the determinative issue involves a medical diagnosis, competent medical evidence is required. This burden typically cannot be met by lay testimony because lay persons are not competent to offer medical opinions. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). The mere fact of an in-service injury is not enough; there must be chronic disability resulting from that injury. If there is no evidence of a chronic condition during service, or an applicable presumption period, then a showing of continuity of symptomatology after service is required to support the claim. See 38 C.F.R. § 3.303(b) (2000). Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. See Savage v. Gober, 10 Vet. App. 488, 495-498 (1997). If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. Id. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2000). A. Alzheimer's disease In relation to the present appeal, the veteran's service medical records show that he was hospitalized in June and July 1958 and that his diagnoses included Alzheimer's disease and organic brain syndrome. A VA examination performed in December 1998 found that the veteran was suffering from a fairly end stage Alzheimer's dementia. The veteran was a poor historian and the veteran's spouse provided the relevant history. The mental status examination found that the veteran was not oriented, and that he exhibited a flattened affect and slow and soft speech. Thought processes and memory were significantly impaired and poor in all areas. Concentration was also impaired. The veteran was diagnosed with senile dementia of the Alzheimer's type, bipolar II disorder by history, and Alzheimer's disease. He was assigned a Global Assessment of Functioning (GAF) score of 25 and his social and occupational impairment was total. In September 1998, the veteran was admitted to a private hospital because of increasing agitation and confusion due to a diagnosis of dementia. The veteran had a history of Alzheimer's disease for two years. During a VA hospitalization from October to November 1999, the veteran was diagnosed with dementia, Alzheimer's type, and vitamin B12 deficiency. He was admitted for evaluation of his dementia. The physician stated that it was possible that the veteran's dementia was related to inadequate nutrition as a POW. Due to the in-service diagnosis of Alzheimer's disease and the current diagnosis of Alzheimer's disease, the Board requested the review and opinion of a medical expert. In December 2000, the Chief of Staff, VA Medical Center in Louisville, Kentucky, submitted an opinion concerning the veteran's claim of entitlement to service connection for Alzheimer's disease. The Board finds this opinion to be exceptionally thorough and well-reasoned. First, the medical expert reviewed the service medical records and noted that the veteran was diagnosed with "psychasthenia reaction, severe" by a neuropsychiatrist shortly after World War II and his confinement as a POW. Then, in June 1958 the veteran was hospitalized and diagnosed with Alzheimer's disease and organic brain syndrome by several physicians, including a psychiatrist and neurologists. The following month, at a consultation at Walter Reed Army Hospital, the medical impressions included typical Alzheimer's disease, no neurological disease, and manic-depressive reaction. The medical expert next discussed the private September 1998 examination that found that the veteran suffered from dementia and the December 1998 VA examination that diagnosed the veteran with senile dementia of the Alzheimer's type and bipolar II disorder by history. The medical expert also considered the VA hospitalization in October and November 1999 for Alzheimer's treatment and the discharge note that possibly related the veteran's dementia to inadequate nutrition as a POW. The medical expert stated that nutritional deficiencies of vitamin B12 and thiamin could bring about a dementing illness, and that the medical literature was divided on whether malnutrition as a POW led to neurological deficiencies or dementia later in life. The expert observed that, in this case, the veteran was diagnosed with Alzheimer's disease during active service. At that time, it was a current diagnosis and it would be unwise to revise it later. Moreover, the veteran's bipolar disorder may have coexisted with the dementia. In addition, the diagnosis of Alzheimer's disease was made by several clinicians from different disciplines. In fact, one of the psychiatrists later became internationally known and served as the Chairman of the Department of Psychiatry at the University of California at Los Angeles and as an expert witness in national trials. Therefore, the expert found it more likely than not, due to the confinement as a POW and the in-service diagnosis, that the veteran's current Alzheimer's disease was due to his period of active service. In summary, based upon the opinion of the medical expert and the medical evidence as a whole, the Board concludes that the evidence supports a grant of service connection for Alzheimer's disease. The record establishes that the veteran was diagnosed with Alzheimer's disease in service and that he presently suffers from Alzheimer's disease. Competent medical evidence relates the in-service diagnosis to the present disability, suggesting that the veteran suffered from a chronic condition since his period of active service. The record contains no medical evidence in contradiction to the finding of the medical expert. Accordingly, the benefit sought on appeal is granted. B. PTSD Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f) (2000). At the present time, the record contains no diagnosis or treatment of PTSD. As aforementioned, the veteran was diagnosed with senile dementia of the Alzheimer's type, bipolar II disorder by history, and Alzheimer's disease during the December 1998 VA examination. At that time, the examiner observed that the veteran was so significantly demented that there was no way to get a reliable estimate of current psychiatric symptomatology. While the veteran may have suffered a stressor as a POW, he did not appear to be suffering from any current symptoms of PTSD and, even if he were, the dementia was so far advanced that it would be difficult to tell. Based upon the above findings, the Board must find that a preponderance of the evidence is against a grant of service connection for PTSD. The Board concedes that the veteran most likely suffered a stressor as a POW. Unfortunately, in the absence of a current diagnosis or identifiable symptomatology, a claim for service connection cannot be granted. The VA examiner found that the veteran was completely impaired due to his Alzheimer's disease and, perhaps due to the Alzheimer's disease, he could discern no symptomatology attributable to PTSD. The Board recognizes that the veteran's spouse believes that he suffered from PTSD; however, lay persons are not competent to offer medical opinions. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Accordingly, the benefit sought on appeal must be denied. II. Increased Rating The veteran believes that his manic depressive psychosis is more disabling than currently evaluated. As to the veteran's claim for a higher rating, the Board finds, as explained above, that all relevant facts have been properly developed, and that all evidence necessary for an equitable resolution of the issue on appeal has been obtained. Therefore, the VA has fulfilled its duty to assist the veteran in developing facts that are pertinent to his claim. See Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, § 3(a), 114 Stat. 2096, 2097-2098 (2000); (to be codified at 38 U.S.C.A. § 5103A). Disability ratings are determined by evaluating the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2000). The record shows that the RO originally granted service connection for manic depressive psychosis in a February 1959 rating decision and assigned a 50 percent evaluation effective from November 1958. Subsequent rating decisions have confirmed and continued this evaluation. In relation to the present appeal, the record contains no treatment records pertaining to the veteran's psychiatric disability. During the December 1998 VA examination, the veteran's wife reported that he received no psychiatric treatment following his discharge from active service. The examiner found that, while there was history that the veteran suffered from some type of psychiatric condition in the past, possibly a bipolar disorder, he now was so significantly demented that there was no way to acquire a reliable estimate of current symptomatology. The veteran's manic depressive psychosis has been assigned a 50 percent schedular evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9432 (2000). Under the general rating formula for mental disorders, a 50 percent evaluation is warranted when symptomatology causes occupational and social impairment with reduced reliability and productivity, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted when psychiatric symptomatology causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, and an inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, or persistent danger of hurting self or others. 38 C.F.R. § 4.130, Diagnostic Code 9432 (2000). In summary, the Board must find that the criteria for an increased rating have not been met. While the veteran does suffer from total occupational and social impairment, this impairment has been attributed to his diagnosis of Alzheimer's disease. Apparently, the debilitating effects of the Alzheimer's disease have superseded those of any other psychiatric disability, and the examiner could not identify any current symptomatology related to the manic depressive psychosis. As no relevant symptomatology has been found, it is impossible for the Board to find that the criteria for the next higher evaluation have been met. Therefore, the appeal is denied. ORDER Service connection for Alzheimer's disease is granted. Service connection for PTSD is denied. An evaluation in excess of 50 percent for manic depressive psychosis is denied. WARREN W. RICE, JR. Member, Board of Veterans' Appeals