Citation Nr: 1317514 Decision Date: 05/29/13 Archive Date: 06/06/13 DOCKET NO. 09-36 900 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for peripheral vascular disease. 2. Entitlement to service connection for cardiovascular disease. 3. Entitlement to service connection for a mental disorder, to include dementia of the vascular and Alzheimer's type, with depressed mood and depression. 4. Entitlement to service connection for bilateral hearing loss. 5. Entitlement to service connection for tinnitus. ATTORNEY FOR THE BOARD A. Bordewyk, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1953 to May 1955. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico, which denied entitlement to service connection for the above claimed disabilities. The claim was remanded by the Board in August 2011 and November 2012 for additional development. 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). FINDINGS OF FACT 1. Peripheral vascular disease did not have its clinical onset in service and is not otherwise related to active duty. 2. Cardiovascular disease did not have its clinical onset in service or for many years thereafter and is not otherwise related to active duty. 3. A mental disorder, to include dementia of the vascular and Alzheimer's type, with depressed mood, did not have its clinical onset in service and is not otherwise related to active duty. 4. Bilateral hearing loss did not have its clinical onset in service or for many years thereafter and is not otherwise related to active duty. 5. Tinnitus did not have its clinical onset in service and is not otherwise related to active duty. CONCLUSIONS OF LAW 1. Peripheral vascular disease was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303 (2012). 2. Cardiovascular disease was not incurred or aggravated in service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. A mental disorder, to include dementia of the vascular and Alzheimer's type, with depressed mood was not incurred or aggravated in service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 4. Bilateral hearing loss was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303 (2012). 5. Tinnitus was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist a veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a letter issued in April 2008, prior to the initial adjudication of the claim, the RO notified the Veteran of the evidence needed to substantiate his claim for service connection. The letter also satisfied the second and third elements of the duty to notify by informing the Veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. He was informed that VA provided ratings based on the rating schedule and was given examples of the evidence he could submit. The Veteran has substantiated his status as a veteran. He was notified of all elements of the Dingess notice, including the disability-rating and effective-date elements of the claims, by the April 2008 letter. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, VA treatment records, and private medical records. The Board has concluded that all VA treatment records, including those from the Durham and San Juan VA Medical Centers (VAMCs) have been obtained. The only service treatment record obtained in this case is a May 1955 separation examination. The rest of the Veteran's service records have not been obtained and the National Personnel Records Center (NPRC) has reported that these records were likely destroyed in a fire at that facility in 1973. Destruction of service treatment records does not create a heightened benefit of the doubt, but only a heightened duty on the part of VA to consider the applicability of the benefit of the doubt, to assist the claimant in developing the claim, and to explain its decision. Cromer v. Nicholson, 19 Vet App 215 (2005); Russo v. Brown, 9 Vet. App. 46, 51 (1996). A request to search the morning or sick reports for the Veteran and his unit was made and a negative response was received in October 2011. A memorandum was issued regarding the unavailability of these records and the Veteran was informed of their unavailability in February 2012. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). The threshold for getting an examination under the VCAA is low. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Board attempted to provide an examination to assess the etiology of his hearing loss and tinnitus, but the Veteran and his spouse reported that he could no longer attend appointments without ambulance transport and could no longer follow simple commands. Therefore, Veteran's spouse stated that she wanted to withdraw the appeals claim and the scheduled examination was canceled. In January 2013, the Veteran and his spouse were issued a notice letter asking whether they wanted to withdraw the current appeal. A response was not received; therefore, the claim must be adjudicated. When a claimant fails to report for a scheduled examination in connection with an original service connection claim, without good cause, the claim will be considered on the basis of the evidence of record. 38 C.F.R. § 3.655 (2012). There is no evidence that the Veteran's condition has improved such that he would be able to participate in an examination. He and his spouse have not requested that the examination be rescheduled. The Veteran has not been afforded VA examinations or medical opinions in response to his remaining claims but the Board does not finding convincing evidence that an incident occurred in service that brought on current disability. The reported in-service injuries are not documented in the record and lay statements regarding inservice incidents are not credible. The issues on appeal were previously before the Board in August 2011 and November 2012, when the case was remanded for additional development. In accordance with the remand instructions, all available VA treatment records have been obtained, the Veteran was scheduled for a VA audiology examination, a search of the morning reports for the Veteran and his unit was made and a negative response was received, and a supplemental statement of the case was issued in February 2013. Since the record reflects compliance with the August 2011 and November 2012 remand instructions, the Board may proceed with adjudication of the claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Legal Criteria-Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current 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 claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element for certain chronic disabilities is through a demonstration of continuity of symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). 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. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may also be granted for a disease first 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). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as cardiovascular disease and organic diseases of the nervous system, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Peripheral Vascular and Cardiovascular Disease The Veteran contends that he incurred a peripheral vascular and cardiovascular disease as a result of cold weather injuries, including frostbite, and a head injury incurred during service. He specifically contends that these injuries led to poor circulation of blood in the extremities and heart, which caused his current disabilities. Post-service medical evidence demonstrates multiple diagnoses including peripheral vascular disease, chronic venous insufficiency, multiple instances of myocardial infarction and cerebrovascular accidents, and coronary artery disease. The May 1955 separation examination, which is the only service record available, is negative for any complaints, treatment, or diagnoses of peripheral vascular or cardiovascular disease or symptoms, as well as any evidence of cold weather injuries or a head injury. The examination of the head, heart, vascular system, upper and lower extremities, and feet were normal at that time. The Veteran is competent to report exposure to the cold, frostbite, and a head injury. Jandreau, 492 F.3d at 1377; see also Buchanan, 451 F.3d at 1337. However, the Veteran filed a claim of service connection for unrelated disability in December 1976 without any report of cold weather injuries, a head injury, or any peripheral vascular or cardiovascular symptoms. It would seem logical that if the Veteran had these problems that persisted since service, he would have mentioned them in his claim. During a May 1977 VA examination, the Veteran did not report any peripheral vascular or cardiovascular symptoms and no such symptoms or diagnoses were found upon examination. It wasn't until he filed a March 2005 claim, almost 50 years post-discharge, that he first reported symptoms related to a frost bite or cold weather injury. The Veteran currently has a diagnosis of dementia and his reliability as a historian is not good. Regardless, the Board notes that even if the Board were to accept his reports of these in-service injuries as credible, service connection would still not be warranted as there is a lack of a nexus between his current disabilities and the reported in-service injuries. The first evidence of any related symptoms was demonstrated more than 40 years after discharge from service, where the Veteran was treated for a stroke in 1999. A June 1999 VA physician stated that there was no clear etiology for his cardiovascular symptoms or the stroke. Throughout VA treatment records from that point forward, the Veteran was noted with the various diagnoses related to the peripheral vascular and cardiovascular system. However, the Veteran's symptoms were never attributed to his reported service injuries by a medical professional. There are no records demonstrating relevant treatment for the more than 40 years between service discharge and his first relevant symptoms or diagnoses. The only evidence of record supporting the finding of a nexus between the current disabilities and service are the statements of the Veteran, which were submitted in connection with his claim for benefits. However, the record reflects a significant gap of over 40 years between discharge and evidence of his first treatment or complaints of either a peripheral vascular or cardiovascular disability. He filed a VA benefits claim in the interim without any mention of such symptoms and there were no peripheral vascular or cardiovascular disabilities or symptoms present or reported upon examination in May 1977. The Veteran has never reported a continuity of symptomatology. In addition, the Veteran lacks the necessary medical expertise to say that his current peripheral vascular or cardiovascular disabilities identified long after service are the result of in-service trauma as opposed to a post-service event or process. The Board acknowledges that the Veteran's spouse, sister, and daughter have submitted statements in support of his claim. However, these statements appear to be based on the Veteran's reports, rather than their own experience or knowledge, and are thus afforded the same weight. Given the lack of competent and credible evidence linking the current peripheral vascular and cardiovascular disabilities, to include peripheral vascular disease, chronic venous insufficiency, multiple instances of myocardial infarction and cerebrovascular accidents, and coronary artery disease to service, the evidence is against a finding of a nexus between them. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim, and it is, therefore, denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C.A. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Mental Disorder The Veteran contends that he incurred a mental disorder as a result of a head injury during service. Post-service medical evidence demonstrates diagnoses of dementia of the vascular and Alzheimer's type, with depressed mood and depression not otherwise specified (NOS). The May 1955 separation examination is negative for any complaints, treatment, or diagnoses of a mental disorder as well as any evidence of a head injury. The head/face and psychiatric examinations were normal at that time. The Veteran is competent to report a head injury. Jandreau, 492 F.3d at 1377; see also Buchanan, 451 F.3d at 1337. However, the Veteran filed a claim of service connection for unrelated disability in December 1976 without any report of a head injury or its residuals. It would seem logical that if the Veteran had residuals of a head injury that persisted since service, he would have mentioned them in his claim. During a May 1977 VA examination, the neurologic and psychiatric portion of the examination yielded normal results. The Veteran currently has a diagnosis of dementia and his reliability as a historian is not good. Regardless, the Board notes that even if the Board were to accept his reports of an inservice head injury as credible, service connection would still not be warranted as there is a lack of a nexus between his current disability and the reported in-service injury. The first evidence of any related symptoms was demonstrated more than 40 years after discharge from service, where cognitive dysfunction was noted following a stroke. Throughout VA treatment records from that point forward, the Veteran was noted with cognitive dysfunction and depressed mood. However, the Veteran's symptoms or diagnoses were never attributed to his reported service injury by a medical professional. In fact, the Veteran's cognitive deficits were at first attributed to his stroke in November 1999. Then, his dementia was attributed to sleep apnea and his vascular disabilities. The Veteran's depressive symptoms have consistently been attributed to his dementia and to other nonservice-related stressors. For example, in May 2007, the Veteran reported psychological symptoms, such as nightmares, resulting from his post-service work as a policeman. The Veteran's wife reported in December 2008 that his depression symptoms stemmed from stressors such as financial problems, a situation in which they were owed a significant debt, and the fact that they were considering bankruptcy. In July 2011, the Veteran reported depression symptoms due to financial problems. There are no records demonstrating relevant treatment for the more than 40 years between service discharge and his first symptoms of a mental disorder. In July 2003, the Veteran reported receiving psychiatric treatment about 13 years prior; however, this treatment was in connection to a divorce he was going through at the time. In some of the more recent VA treatment records, particularly in records between December 2008 and June 2009, the Veteran reported that he had had mental illness after service but that he did not seek any psychiatric treatment. The Veteran was not more specific and this history was first reported after he filed his current claim for benefits. The Board notes that the VA psychiatric and neurologic examination in May 1977 was normal. Therefore, even if the Veteran had such symptoms after service, he was found to be without a diagnosed disability more than 20 years post-discharge. The only evidence of record supporting the finding of a nexus between the current disability and service are the statements of the Veteran, which were submitted in connection with his claim for benefits. However, the record reflects a significant gap of over 40 years between discharge and evidence of his first treatment or complaints of a mental disorder. He filed a VA benefits claim in the interim without any mention of such symptoms and there were head injury residuals or neuropsychiatric symptoms present or reported upon examination in May 1977. The Veteran has never reported a continuity of symptomatology. Moreover, his related symptoms or diagnoses have been found by treatment providers or reported by the Veteran and his spouse to be due to nonservice-related stressors, diseases, or events, including financial issues, his post-service employment, stroke, vascular disabilities, and sleep apnea. In addition, the Veteran lacks the necessary medical expertise to say that any mental disorder, including dementia or depression, identified long after service is the result of in-service trauma as opposed to a post-service event or process. The Board acknowledges that the Veteran's spouse, sister, and daughter have submitted statements in support of his claim. However, these statements appear to be based on the Veteran's reports, rather than their own experience or knowledge, and are thus afforded the same weight. Given the lack of convincing evidence linking a current mental disorder, to include dementia of the vascular and Alzheimer's type, with depressed mood and depression to service, the evidence is against a finding of a nexus between them. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim, and it is, therefore, denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C.A. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Bilateral Hearing Loss and Tinnitus Entitlement to service connection for impaired hearing is subject to the additional requirements of 38 C.F.R. § 3.385 (2012), which provides that service connection for impaired hearing shall be established when hearing acuity meets certain pure tone and speech recognition criteria. Hearing loss status will be considered a disability for the purposes of service connection when the auditory thresholds in any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater, the auditory thresholds for at least three of these frequencies are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. A July 2006 VA audiology consultation included audiogram results which demonstrated hearing loss under 38 C.F.R. § 3.385, as auditory thresholds were found to be greater than 40 decibels at 3000 and 4000 Hertz bilaterally. In addition, tinnitus was noted by history. The Veteran is competent to report noise exposure, difficulty hearing and ringing in the ears in service. Jandreau, 492 F.3d at 1377; see also Buchanan, 451 F.3d at 1337. However, the Veteran filed a claim of service connection for unrelated disability in December 1976 without any report of auditory problems. It would seem logical that if the Veteran had these problems that persisted since service, he would have mentioned them in his claim. The Veteran currently has dementia. The Board finds that the Veteran is not a reliable historian. During a May 1977 VA examination, his ears were found to be clear and the examiner specifically indicated that hearing loss was not noted. The Veteran made no complaints of tinnitus or hearing difficulty. The first evidence of any hearing-related symptoms was demonstrated more than 45 years after discharge from service, in a February 2001 VA treatment record, where "poor audition" was noted based on the Veteran's reports. In June 2001, mild to severe bilateral sensorineural hearing loss was noted but an audiogram was not included with the record. The Veteran reported during July and September 2003 VA treatment that many years ago, a gun was fired at close range by his right ear and he had had hearing loss and tinnitus in that ear ever since. During the July 2006 VA audiology consultation, he reported 2 years of noise exposure during service and 28 years of post-service noise exposure as a policeman and helicopter pilot. As noted above, the May 1955 separation demonstrated that the ears were found to be normal, there were no complaints noted regarding hearing loss or tinnitus, a whisper voice test was normal bilaterally, and an audiogram was not performed. Pursuant to the November 2012 Board remand, the Veteran was scheduled for a VA audiology examination to obtain an opinion regarding the etiology of his bilateral hearing loss and tinnitus. In December 2012, however, the Veteran's spouse reported that he required ambulance transport for all appointments and was not able to follow directions or commands. She indicated that she wanted to withdraw the appeals claim. Based on this conversation, the Veteran's scheduled VA examination was canceled and a new examination was not rescheduled. Information from such an examination may have provided support for the Veteran's contentions. The only evidence of record supporting the finding of a nexus between current hearing loss and tinnitus and service are the statements of the Veteran, which were submitted in connection with his claim for benefits. However, the record reflects a significant gap of over 45 years between discharge and evidence of his first treatment or complaints of hearing loss. He filed a VA benefits claim in 1976 without any mention of auditory symptoms and neither hearing loss not tinnitus was present or reported upon examination in May 1977. Moreover, the Veteran has reported significant post-service acoustic trauma for 28 years. Based on the foregoing, the Board finds the Veteran's statements asserting a nexus between current hearing loss and tinnitus and in-service noise exposure to not be credible. In addition, the Veteran lacks the necessary medical expertise to say that a hearing loss or tinnitus identified long after service is the result of in-service trauma as opposed to a post-service event or process. Given the lack of competent and credible evidence linking the current bilateral hearing loss and tinnitus to service, the evidence is against a finding of a nexus between them. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim, and it is, therefore, denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C.A. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Service connection for peripheral vascular disease is denied. Service connection for cardiovascular disease is denied. Service connection for a mental disorder, including dementia of the vascular and Alzheimer's type, with depressed mood and depression is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs