Citation Nr: 1308784 Decision Date: 03/15/13 Archive Date: 03/25/13 DOCKET NO. 10-29 388 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, not including dementia of the Alzheimer's type, to include depression and anxiety, including on a secondary basis. 2. Entitlement to service connection for dementia of the Alzheimer's type, including on a secondary basis. 3. Entitlement to service connection for tinnitus. 4. Entitlement to special monthly compensation based on the need for the regular aid and attendance of another person. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from October 1951 to January 1953, including in the Republic of Korea during the Korean Conflict. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied, in pertinent part, the Veteran's claims of service connection for an acquired psychiatric disorder (to include on a secondary basis) and for tinnitus and for special monthly compensation based on the need for the regular aid & attendance of another person. The Veteran disagreed with this decision in March 2009. He perfected a timely appeal in May 2010. Although the Veteran initially requested a Travel Board hearing when he perfected a timely appeal in May 2010, he withdrew his Board hearing request in June 2010 correspondence. See 38 C.F.R. § 20.704 (2012). Because the Veteran currently lives within the jurisdiction of the RO in Detroit, Michigan, that facility retains jurisdiction in this appeal. In an August 2010 rating decision, the RO found the Veteran to be incompetent for purposes of disbursing VA disability compensation payments. The Veteran's wife (the appellant in this case) was appointed his spouse payee in May 2011. As applicable law provides that certification is for administrative purposes and does not serve either to confer or deprive the Board jurisdiction of an issue, the Board has construed the psychiatric issues, for purposes of this appeal, to reflect the broad interpretation required by Clemons v. Shinseki, 23 Vet. App. 1 (2009). Id. at 7-9 (defining the scope of the claim at the time the claim is filed). Accordingly, the issues on appeal are as listed on the cover page. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for dementia of the Alzheimer's type, including as due to the service-connected below the knee amputation of the left leg, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The Veteran was engaged in combat with the enemy. 2. An acquired psychiatric disorder (other than dementia of the Alzheimer's type), to include posttraumatic stress disorder (PTSD), a depressive disorder and an anxiety disorder, is not demonstrated by the evidence of record. 3. Tinnitus is not demonstrated by the lay or medical evidence of record. 4. The record evidence shows that the Veteran needs the regular aid and attendance of another person because he is unable to dress and undress himself, bathe himself, and needs help adjusting his prosthesis for his below the knee amputation of the left leg. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for an acquired psychiatric disorder (other than dementia of the Alzheimer's type), to include PTSD, a depressive disorder, and an anxiety disorder, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1137, 1154(b), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 3.307, 3.309(a), 3.310 (2012). 2. The criteria for establishing service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 3. The criteria for special monthly compensation based on the need for aid and attendance of another person have been met. 38 U.S.C.A. §§ 1114(l), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.350(b)(3), 3.352(a), 4.3 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In a letter issued in January 2009, VA notified the Veteran of the information and evidence needed to substantiate and complete his claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). This letter informed the Veteran to submit medical evidence relating the claimed disabilities to active service, demonstrating his entitlement to special monthly compensation based on the need for aid & attendance, and noted other types of evidence the Veteran could submit in support of his claims. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of this letter, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service-connection claim was provided in the January 2009 VCAA notice letter and in January and June 2010, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board, although he declined to do so. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed and no relevant evidence was located there. The Veteran also does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the Veteran shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. An examination or opinion shall be treated as being necessary to make a decision on the claim if the evidence of record, taking into consideration all information and lay or medical evidence (including statements of the claimant) contains competent evidence that the Veteran has a current disability, or persistent or recurring symptoms of disability; and indicates that the disability or symptoms may be associated with the Veteran's active service; but does not contain sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran also has been provided with VA examinations which address the contended causal relationship between the claimed disabilities and active service and for the purpose of determining his entitlement to special monthly compensation based on the need for regular aid & attendance. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Service Connection Claims Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claim in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013), the Federal Circuit recently overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013); see also 38 C.F.R. § 3.309(a). Because tinnitus is not explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to that claim. By contrast, because psychoses are considered "chronic" disabilities under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating the Veteran's service connection claim for an acquired psychiatric disability (other than dementia of the Alzheimer's type), to include depression and anxiety. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) (pertaining to combat Veterans). In the case of any Veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Satisfactory lay or other evidence under section 1154(b) has been defined as "credible evidence." See Collette v. Brown, 82 F.3d 389, 393 (Fed. Cir. 1996). However, these provisions deal with the question of whether a particular disease or injury occurred in service; that is, what happened then, and not the question of either current disability or nexus to service, for both of which competent evidence is generally required. In other words, these provisions do not presumptively establish service connection for a combat Veteran; rather, they relax the evidentiary requirements for noting what happened in service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997); Libertine v. Brown, 9 Vet. App. 521, 524 (1996). Service connection also may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or, (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(a)-(b); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993) (explaining 38 C.F.R. § 3.310(a)); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (explaining 38 C.F.R. § 3.310(b)). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Analysis A. Psychiatric disorder (other than dementia of the Alzheimer's type) The Veteran's service treatment records show no complaints of or treatment for a psychiatric disorder during service. These records document the Veteran's in-service injury to the left leg while in combat in Korea during the Korean Conflict which resulted in a below the knee amputation of the left leg. However, in December 1952, the Medical Board entered a 1 for the "S" category (psychiatric) under the "PULHES" physical profile of the Veteran, indicating no psychiatric pathology. The post-service evidence shows that, in an October 2008 note, L. F. B., M.D. wrote that the Veteran "has significant depression and increasing dementia [that] blocks him from doing things." In statements on a January 2009 VA Form 21-4138, the Veteran's wife asserted that her husband experienced depression "as he cannot lead the life he was use[d] to (running a campground)." She also asserted that her husband experienced anxiety because he was totally dependent on her. In statements on his March 2009 Notice of Disagreement, the Veteran contended that he experienced "anxiety and depression because of a loss of my leg and the fact I cannot do anything on my own and my doctors outlined that fact the loss of my leg under combat conditions has more than caused me anxiety and depression since the end of the Korean War." On VA examination in April 2010, the Veteran's wife reported that her husband "misses doing a lot of the things he used to do...he can't get around unless he is in a wheelchair or in a rocker...his level of physical activity almost does not exist now." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran's wife also stated, "I think medication is helping him just hold his own...there are good days and bad days with his memory." It was noted that the Veteran was being treated for Alzheimer's disease and received ongoing care from his wife. He presented in a wheelchair and was unable to identify the year, day of the week, or current President of the United States. The VA examiner concluded that the Veteran was suffering from moderate to severe Alzheimer's disease which resulted in significantly impaired sustained attention/concentration and information processing. His wife "provided nearly all of the reliable collateral information" during the examination. The Veteran reported that he was engaged in combat in Korea, shattering his left leg below the knee and undergoing surgery to amputate the left leg below the knee. The Veteran's wife reported that, although the Veteran no longer had any "bad dreams" about his in-service combat experiences, "sometimes he forgets where he is in the morning, and he still thinks he is at a campground we ran for quite a few years...he will forget that people passed away, and he will forget places." Mental status examination of the Veteran in April 2010 showed he was clean, neatly groomed, appropriately and casually dressed, lethargic psychomotor activity, impoverished speech that was soft or whispered, slow, and mumbled, moderate to severe deficits specific to attention concentration information processing, intact orientation only to person but not to time and place, rambling thought process with paucity of ideas, poverty of thought, no delusions, an inability to understand the outcome of behavior, and no hallucinations, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal or suicidal thoughts, fair impulse control, a shifting mental state and mood consistent with Alzheimer's Disease, and an inability to maintain minimum personal hygiene. The Veteran's remote memory was mildly impaired and his recent and immediate memory was severely impaired. The Veteran's PTSD screen was negative. He did not know the amount of his benefit payment, his monthly bills, how to handle payments prudently, and did not personally handle money and pay the bills. He was not capable of managing his financial affairs. "The Veteran's wife currently handles all of the Veteran's financial affairs." The Veteran had retired in 1984 after working for 30 years due to his age or duration of work. The VA examiner concluded that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD. This examiner stated: [B]ased on his current clinical presentation, [the Veteran] appears to be suffering from mid-stage Alzheimer's Dementia. He is unable to appropriately answer questions specific to his recent psychosocial functioning and memories...[T]he Veteran's wife provided nearly all of the reliable information gathered during the instant evaluation session. It is within the realm of possibility [that the Veteran] suffered from symptomatology characteristic of PTSD as recently as 2005. Unfortunately, this examiner can only provide a diagnosis reflecting the Veteran's current functioning, and had he been evaluated for PTSD at an earlier time, probably would have met [the] diagnostic criteria for this condition. At this time, however, there is no enough clinical evidence to support a diagnosis of PTSD on Axis I, and as outlined by the DSM-IV-TR. No other Anxiety disorders were identified. In addition, there is no indication this man is suffering from clinical depression, though, bouts of mild depression appear to run parallel to this man's ongoing cognitive decline and associated physical limitations. The Axis I diagnosis was dementia of the Alzheimer's type, with late onset, without behavior disturbance. There was no diagnosis on Axis II. The Board acknowledges the Veteran's assertions that his claimed acquired psychiatric disorder (other than dementia of the Alzheimer's type), to include depression and anxiety, is related to active service or, alternatively, his service-connected below the knee amputation of the left leg caused or contributed to his claimed acquired psychiatric disability (other than dementia of the Alzheimer's type). Although the Veteran's service treatment records confirm that he had an below the knee amputation of the left leg following a combat-related injury during active service in Korea, these same service records also reveal no complaint, finding, or pathology indicative of a psychiatric disorder at any time during active service. In fact, after extensive hospital care and evaluation for his combat injury, the Medical Board entered a 1 for the "S" category (psychiatric) under the "PULHES" physical profile of the Veteran, indicating that he exhibited no psychiatric pathology. Crucially, the evidence of record shows that the VA examiner, after a comprehensive evaluation of the Veteran, specifically concluded that the Veteran did not meet the diagnostic criteria for PTSD and identified no other anxiety disorders experienced by the Veteran. This examiner only diagnosed the Veteran as having dementia of the Alzheimer's type following VA examination in April 2010. The Board also acknowledges that, in an October 2008 note, Dr. L. F. B. stated that the Veteran "has significant depression...[that] blocks him from doing things." The Board finds that this opinion is less than probative on the issue of whether the Veteran experiences current acquired psychiatric disorder (other than dementia of the Alzheimer's type) which could be attributed to active service. It does not address the contended etiological relationship between the Veteran's claimed acquired psychiatric disorder (other than dementia of the Alzheimer's type) and active service. Nor does it address the contended causal relationship between the Veteran's service-connected below the knee amputation of the left leg and his claimed acquired psychiatric disorder (other than dementia of the Alzheimer's type). Although Dr. L. F. B.'s opinion suggests the presence of depression (at least as of October 2008), the VA examiner, in considering the same as noted by Dr. B., found in April 2010 that the Veteran did not experience clinical depression. As indicated above, in April 2010, the VA examiner interviewed the Veteran and his spouse, took into account the Veteran's combat stressor, the post service lay and medical evidence indicating the Veteran's episodes of depression, as well as affects of his service-connected conditions, and ultimately determined that the Veteran did not have a diagnosis of clinical depression. Further, unlike Dr. B.'s script note, the April 2010 VA examination report constitutes probative and persuasive evidence that the Veteran's mental health symptoms are not indicative of a diagnosis of clinical depression. The VA examiner's opinion is explained and supported as required by Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Hence, as the preponderance of the evidence is against a probative diagnosis of a depressive disorder, this aspect of the claim must be denied. The Board acknowledges further that, in his April 2010 opinion, the VA examiner stated that, although there were no identified anxiety disorders or a valid diagnosis of PTSD based on an examination of the Veteran's current psychosocial functioning, it was "within the realm of possibility [that the Veteran] suffered from symptomatology characteristic of PTSD as recently as 2005." This examiner also stated that, "had [the Veteran] been evaluated for PTSD at an earlier time, [he] probably would have met [the] diagnostic criteria for this condition." Although seeming to suggest a retrospective assessment, the VA examiner, based on a review of the entire record, qualified that assessment and explained that there is not enough clinical evidence (which included a negative PTSD screen) to support a diagnosis of PTSD on Axis I, and as outlined by the DSM-IV-TR. Hence, the Board finds that the preponderance of the evidence is against a probative PTSD diagnosis. As a result, any claim of service connection for PTSD, therefore, fails on the basis that all three elements for such a showing under 38 C.F.R. § 3.304(f), have not been met. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection is not warranted in the absence of proof of current disability. The Board has also considered whether the Veteran has a diagnosis of an anxiety disorder at any time during the pendency of this appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, the April 2010 VA psychiatric evaluation results revealed no indication that the Veteran has an anxiety disorder. The other medical evidence of record does not refute this finding. The Board also notes that a contrary opinion of record comes from the Veteran and his spouse, who believe that the Veteran now suffers from an anxiety disorder. The Board recognizes that there are instances in which a lay person can provide probative evidence of medical matters. A layperson may be competent to offer testimony on certain medical matters, such as describing symptoms observable to the naked eye (or even diagnosing simple conditions such as a dislocated shoulder). See Jandreau v. Nicholson, 492 Vet. App. 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). However, as laypersons, the Veteran and his spouse are not competent to diagnose an anxiety disorder, which is a complicated diagnosis defined by criteria set forth in DSM-IV. Therefore, in the absence of competent medical evidence showing a current diagnosis of an anxiety disorder, this aspect of the claim for service connection must be denied. B. Tinnitus The Veteran contends that he entitled to service connection for tinnitus because he was exposed to loud noises during his active combat service in Korea. The evidence of record does not support his assertions, however. It shows instead that, although the Veteran had significant in-service noise exposure while engaged in combat during the Korean Conflict, he does not experience any current tinnitus which is attributable to service. The Veteran's service treatment records again confirm that he engaged in combat in Korea and incurred a below the knee amputation of the left leg, as a result of being injured by mortar fire on Bunker Hill. These records and the Veteran's DD Form 214 indicate that he served as an infantryman while in combat in Korea. Having reviewed the record evidence, the Board finds it reasonable to conclude that the Veteran was exposed to loud noise as an infantryman who saw active combat service in Korea during the Korean Conflict. See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d). Although the Veteran experienced noise exposure in service during his active combat service in Korea, tinnitus is not shown to be a result of this exposure. In this regard, the service treatment records also show that, at his enlistment physical examination in October 1951, his hearing was "15/15" (or within normal limits) bilaterally. After he was wounded in combat in Korea in August 1952, the Veteran had a lengthy hospitalization for treatment of his below the knee amputation of the left leg. While diminished hearing in the left ear was noted in September 1952, the Medical Board, in December 1952, entered a 1 for the "H" category (hearing and ears) under the "PULHES" physical profile of the Veteran. He subsequently was discharged medically from active service in January 1953 after a Medical Board found him unfit for continued service due to his below the knee amputation of the left leg. Similarly, the results of the VA examination in August 1953 revealed that the Veteran's hearing and ears were normal. On VA audiology examination in March 2010, although reporting his accounts of loud noise exposure in service, the Veteran, in fact, denied experiencing symptoms of tinnitus. The Board would note that in Charles v. Principi, 16 Vet. App. 370, 374-375 (2002), the Court specifically held that tinnitus is a condition which is capable of lay observation. See also Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). In lay statements of 2008 and 2009, the Veteran and his spouse gave a history of acoustic trauma sustained during active combat duty. The Veteran and his spouse are competent to present such evidence and the Board does not question the credibility of this account of sustaining acoustic trauma in service. However, the fact remains that even in their 2008 and 2009 statements, they failed to indicate that tinnitus was currently or had recently been manifested. In this regard, they merely provide a vague account of the Veteran having had a history of hearing loud noises while engaged in combat described as a result of excessive exposure to small arms fire and explosions from rocket and mortar while stationed in Korea. Accordingly, this lay account, particularly when viewed in conjunction with the other clinical evidence dated since 2008 is insufficient to establish tinnitus as a current manifestation/diagnosis. In essence, a comprehensive review of both the lay and clinical evidence reveals no indication of currently manifested tinnitus. The law limits entitlement for service-related diseases and injuries to cases where the underlying in-service incident has resulted in a current disability. Degmetich v. Brown, 104 F. 3d 1328, 1332 (Fed. Cir. 1997); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Thus, because the evidence does not reveal manifestations of tinnitus at any time from 2008 forward, there is no evidence of the currently claimed disability and Hickson element (1) therefore has not been met; the Veteran's claim fails on this basis alone. See Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (noting that service connection may not be granted unless a current disability exists). Accordingly, as there is no evidence of a current disability, the preponderance of the evidence is against the claim and service connection for tinnitus must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Special Monthly Compensation Claim Special monthly compensation is payable under 38 U.S.C.A. § 1114(l) if, as the result of service-connected disability, the Veteran is permanently bedridden or is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C.A. § 1114(l) (West 2002 & Supp. 2012); 38 C.F.R. § 3.350(b) (2012). Need for aid and attendance means being so helpless as to require the regular aid and attendance of another person. 38 C.F.R. § 3.350(b). As it pertains to the present case, criteria for establishing such need include whether the Veteran is permanently bedridden or is so helpless as to be in need of regular aid and attendance as determined under criteria enumerated under 38 C.F.R. § 3.352(a). Under 38 C.F.R. § 3.352(a), the following factors will be accorded consideration in determining whether the Veteran is in need of regular aid and attendance of another person: (1) inability of the Veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; (3) inability of the Veteran to feed himself because of the loss of coordination of upper extremities or because of extreme weakness; (4) inability to attend to the wants of nature; or (5) physical or mental incapacity which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a) (2012). It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance not that there is a constant need for aid and attendance. 38 C.F.R. § 3.352(a); see Turco v. Brown, 9 Vet. App. 222, 224 (1996) (holding that at least one factor listed in § 3.352(a) must be present to grant special monthly compensation based on the need for aid and attendance). For the purposes of 38 C.F.R. § 3.352(a), "bedridden" will be a proper basis for the determination of whether the Veteran is in need of regular aid and attendance of another person. "Bedridden" will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). Analysis The Board finds that the evidence supports granting the Veteran's claim of entitlement to special monthly compensation based on the need for regular aid & attendance of another person. The Veteran contends that he is entitled to special monthly compensation because he is completely dependent on his wife (the appellant in this case) for his activities of daily living, to include specifically dressing and undressing himself, adjusting his left leg prosthesis, and bathing himself. The record evidence supports the assertions regarding the Veteran's need for the regular aid & attendance of another person. For example, when he filed his claim for special monthly compensation in October 2008, the Veteran attached a copy of a VA Form 21-2680, "Examination For Housebound Status Or Permanent Need For Regular Aid And Attendance," completed by a VA clinician in October 2008. A review of this examination report indicates that the Veteran's complaints included difficulty walking, shortness of breath, and advanced osteoarthritis in the right knee. It was noted that the Veteran was unable to walk although his "posture is OK." The Veteran's wife helped him with clothing and his left leg prosthesis. His balance was "very poor." His bladder control was lost. He was "very, very dizzy." His memory was poor. He was unable to travel alone and his wife had come with him to this examination. It was noted that he "sits at home all day." He was unable to walk without the assistance of another person and unable to leave his house alone. He used a wheelchair for locomotion and had advancing dementia. The VA clinician concluded that the Veteran required the daily personal health care services of a skilled provider without which he would require hospital, nursing home, or other institutional care although he also noted that the Veteran's "wife does all services." The diagnoses were dementia, advanced osteoarthritis of the right knee, a left leg prosthesis, and chronic obstructive pulmonary disease. In statements on a January 2009 VA Form 21-4138, the Veteran's wife stated that "he is unable to walk beyond 20 [feet because] his legs just give out on him." The Veteran's right leg was "very weak as it has been compensating for left leg amputation." In a March 2009 letter, D.A.D., D.O., stated that the Veteran's wife "has provided for him 24-hours a day at his home." Dr. D.D. also stated that the Veteran "required 24-hour care due to poor memory, weakness, back pain, and amputation of his leg." This physician certified that the Veteran "continues to need 24-hour a day physical assistance, general supervision, and at this point, his wife has been the only one providing that." In a March 2009 letter, Dr. L.B. stated that the Veteran's wife helped him "with bathing, shower, daily routines (in & out of bed, dress, medications)." In a March 2009 statement, the Veteran's wife stated that he "is unable to dress or undress without my assistance. He needs complete assistance to bath[e] and general clean up" and help putting on his left leg prosthesis. "He is incompetent and needs assistance coming or going into [the] bathroom. He leaves home only for doctor or other appointments and this is done with help from others with a wheelchair." A review of private rehabilitation records, date-stamped as received by the RO in September 2009, shows that the Veteran was treated as an in-patient at a private rehabilitation center in January and in August 2008 for impaired mobility, activities of daily living, and cognition (among other things). In January 2008, it was noted that, following 4-vessel heart bypass surgery, the Veteran's post-operative complications included "decompensation of his dementia" and prompted his stay in a rehabilitation facility. "[The Veteran] gave inconsistent function based on his dementia." Neuropsychiatric testing revealed decompensated dementia. Although it was noted that the Veteran's "ability to put on his own prosthesis improved, but not to the point it was felt that in his own home environment he might make some improvements back to his baseline." It was noted that the Veteran was discharged to his home under 24-hour supervision by his wife. In August 2008, the Veteran was readmitted to the rehabilitation facility following increased confusion at home. He was discharged home 1 week following his admission. On VA psychiatric examination on April 15, 2010, it was noted that the Veteran presented in a wheelchair. Although the Veteran "used to enjoy working out in his workshop...over the past few years, he has become less interested in this activity." He also no longer hunted or fished due to his increased aged and "suggested Dementia." It was noted that the Veteran's wife "is currently assisting the Veteran in appropriately addressing his activities of daily living (ADL's)" which were "severely impaired." The VA examiner concluded that the Veteran was "unable to effectively manage" his activities of daily living and was "completely dependent upon his wife for continued care." This examiner also concluded that the Veteran had "[v]ery severe impairment of memory and attention and very poor psychosocial functioning due to dementia. This [Veteran] is completely dependent upon his wife for the appropriate management of his activities of daily living." On VA aid & attendance examination 1 day later on April 16, 2010, no complaints were noted. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. It was noted that the Veteran was not permanently bedridden or hospitalized and could travel beyond his current domicile. The Veteran had travelled to this examination in a private vehicle accompanied by a family member. He was able to leave his home and had 3 grown children living nearby whom he visited. He had a left below the knee amputation with prosthesis. He never experienced dizziness, had only moderate short-term memory loss, and experienced occasional (less than weekly) difficulty ambulating due to imbalance. His left below the knee amputation also affected his ability to protect himself from the daily environment. He was unable to dress and undress and bathe. Physical examination showed a good current nutritional status, ambulating with a walker, an ability to walk without the assistance of another person only within the home, an unrestricted ability to leave the home, no permanent functional impairments other than the amputation, best corrected vision 5/200 or worse in both eyes, no cervical or thoracolumbar spine limitation of motion or deformity, normal function of the upper extremities, a slow gait, normal balance, and a left below the knee amputation with prosthesis. The VA examiner stated that the Veteran "is self sufficient in his activities of daily living." He lived in his own home with his wife who was able to assist him as needed. He also had been diagnosed as having dementia. The diagnosis was left below the knee amputation. The Board recognizes that the Veteran's wife has reported consistently that she provides assistance to the Veteran with bathing, dressing and undressing, and in putting on and taking off his left leg prosthesis. The Veteran's wife reported in her March 2009 statement that the Veteran only was able to leave his home for medical appointments and examinations and he needed a wheelchair and the assistance of others to leave his home. The record evidence supports these assertions. It demonstrates that, at least as of mid-2008, the Veteran required 24-hour supervision by his wife (as noted in his private in-patient rehabilitation records). Thus, the Board finds that the Veteran is so helpless as to require the regular aid and attendance of another person (in this case, his wife). 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b). The Board notes in this regard that there is evidence both for and against a finding that the Veteran is able to complete his activities of daily living without the regular aid and attendance of another person. For example, on VA psychiatric examination on April 15, 2010, the examiner stated that the Veteran's activities of daily living were "severely impaired" and he was completely dependent on his wife to complete them. This examiner also found that the Veteran was "unable to effectively manage" his activities of daily living due to his dementia. By contrast, on VA aid & attendance examination 1 day later on April 16, 2010, a different VA examiner found that the Veteran was "self sufficient" in his activities of daily living although his wife was able to assist him as needed. It is not clear from a review of the record evidence why there is a conflict concerning whether the Veteran can complete his activities of daily living with assistance, although this evidence was obtained on successive days in April 2010 from 2 different VA examiners. Having reviewed the record evidence, the Board finds that it is in equipoise on whether the Veteran is able to complete his activities of daily living without the need for the regular aid & attendance of another person. The Board notes in this regard that, although the April 2010 VA examiners reached the opposite conclusion concerning the Veteran's activities of daily living, both of these examiners found that the Veteran was unable to dress and undress himself or bathe without the assistance of another person (in this case, his wife). Resolving any reasonable doubt in the Veteran's favor, the Board finds that the Veteran is not able to complete his activities of daily living without the need for the regular aid & attendance of another person. See 38 C.F.R. §§ 3.102, 4.3. In summary, because at least one of the criteria enumerated in 38 C.F.R. § 3.352(a) are met, the Board finds that special monthly compensation based on the need for the regular aid & attendance of another person is warranted. See 38 U.S.C.A. § 1114(l); 38 C.F.R. §§ 3.350(b)(3), 3.352(a). ORDER Entitlement to service connection for an acquired psychiatric disability (other than dementia of the Alzheimer's type), to include PTSD, a depressive disorder and anxiety disorder including, including in a secondary basis, is denied. Entitlement to service connection for tinnitus is denied. Entitlement to special monthly compensation based on the need for the regular aid & attendance of another person is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The record evidence demonstrates that, following VA examination in April 2010, the VA examiner diagnosed the Veteran as having dementia of the Alzheimer's type, with late onset, without behavior disturbance, on Axis I. Unfortunately, this examiner did not provide an opinion concerning the contended causal relationship between the Veteran's dementia of the Alzheimer's type and active service. Nor did this VA examiner provide an opinion concerning the contended causal relationship between the Veteran's service-connected disabilities, specifically the below the knee amputation of the left leg and his dementia of the Alzheimer's type. The Court has held that, when VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Given the deficiencies in the April 2010 VA examination with respect to the lack of etiological opinions for the Veteran's dementia of the Alzheimer's type, this examination report must be returned to the VA examiner as inadequate. See also 38 C.F.R. § 4.2 (2012). The Board finds that, on remand, the April 2010 VA examiner should be asked to provide an addendum to this examination report in which he addresses the contended causal relationship between the Veteran's dementia of the Alzheimer's type and active service, to include as due to service-connected below the knee amputation of the left leg. If this examiner is not available, then the claims file and a copy of this remand should be forwarded to another appropriate VA examiner for his or her review. Because the Veteran is diagnosed as having moderate to severe (or mid-stage) Alzheimer's dementia, he should not be called in for another in-person VA examination. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran's claims folder to the VA examiner who conducted the Veteran's psychiatric examination on April 15, 2010, and request that the examiner provide an addendum to this examination report. A copy of this remand is to be made available to the examiner for review. In his addendum to the April 15, 2010, VA psychiatric examination report, this VA examiner should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's dementia of the Alzheimer's type was caused by or is related to active service or any incident of service. This examiner also should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's dementia of the Alzheimer's type was caused or aggravated (permanently worsened beyond normal progression) by the Veteran's service-connected disabilities (i.e., below the knee amputation of the left leg; wound of right buttock, Muscle Group XVII; degenerative arthritis of right low extremity; osteoporosis of the left hip and knee; and right leg scar, Muscle Group XI) either alone or acting together in concert; irrespective of any contribution due to nonservice-connected disabilities. Please explain the reasons for your opinion. If the examiner finds that the Veteran's dementia of the Alzheimer's type was aggravated by his service-connected disabilities, either alone or acting together in concert, the examiner should quantify the degree of aggravation, if possible. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. If, any only if, the VA examiner who conducted the Veteran's April 15, 2010, VA psychiatric examination is unavailable, then forward the claims file and a copy of this remand to an appropriate VA physician for his or her review. Do not call the Veteran in for another in-person examination. Based on a review of the claims file, to include the April 15, 2010, VA psychiatric examination report, and a copy of this remand, the VA physician is asked to opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's dementia of the Alzheimer's type was caused by or is related to active service or any incident of service. This examiner also should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's dementia of the Alzheimer's type was caused or aggravated (permanently worsened beyond normal progression) by the Veteran's service-connected disabilities (i.e., below the knee amputation of the left leg; wound of right buttock, Muscle Group XVII; degenerative arthritis of right low extremity; osteoporosis of the left hip and knee; and right leg scar, Muscle Group XI) either alone or acting together in concert; irrespective of any contribution due to nonservice-connected disabilities. Please explain the reasons for your opinion. If the examiner finds that the Veteran's dementia of the Alzheimer's type was aggravated by his service-connected disabilities, either alone or acting together in concert, the examiner should quantify the degree of aggravation, if possible. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Review all evidence received since the last prior adjudication and readjudicate the Veteran's claim of service connection for dementia of the Alzheimer's type, including on a secondary basis. If the determination remains unfavorable to the Veteran, then the RO should issue a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response by the Veteran and his service representative. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs