Citation Nr: 18155037 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 12-15 568 DATE: December 4, 2018 ORDER Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with major depressive disorder is denied. Prior to June 14, 2007, entitlement to a total disability rating based on individual unemployability (TDIU) is denied. Beginning June 14, 2007, entitlement to TDIU is granted, subject to the laws and regulations governing the payment of monetary benefits. Beginning June 14, 2007, entitlement to special monthly compensation (SMC) at the statutory housebound rate is granted, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. Throughout the period of the appeal, the competent and probative evidence of record demonstrates that Veteran’s PTSD with major depressive disorder has been manifested by, at worst, occupational and social impairment with reduced reliability. 2. Prior to June 14, 2007, the competent and probative evidence of record demonstrates that the Veteran’s service-connected disabilities did not preclude him from obtaining and maintaining substantially gainful employment consistent with his education and experience. 3. Beginning June 14, 2007, the competent and probative evidence of record demonstrates that the Veteran’s service-connected disabilities precluded him from obtaining and maintaining substantially gainful employment consistent with his education and experience. 4. Beginning June 14, 2007, the Veteran has been unemployable due solely to his service-connected residuals of a stroke, and has also had additional service-connected disabilities rated at least 60 percent disabling. CONCLUSIONS OF LAW 1. Throughout the period of the appeal, the criteria for a disability rating in excess of 50 percent for PTSD with major depressive disorder have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 2. Prior to June 14, 2007, the criteria for entitlement to TDIU have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 4.16, 4.19 (2017). 3. Beginning June 14, 2007, the criteria for entitlement to TDIU have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 4.16, 4.19 (2017). 4. Beginning June 14, 2007, the criteria for SMC at the housebound rate have been met. 38 U.S.C. § 1114(s) (2012); 38 C.F.R. § 3.350(i)(2) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board acknowledges that in an August 2018 written statement the Veteran raised the issues of entitlement to an automobile allowance, entitlement to aid and attendance, and entitlement to a special home adaption grant or specially adapted housing. The Veteran is advised that his statements do not meet the standards of an intent to file under 38 C.F.R. § 3.155(b) or those of a complete claim under 38 C.F.R. § 3.155(a). Additionally, in a letter dated September 2018, the Agency of Original Jurisdiction (AOJ) notified the Veteran as to the procedures required under 38 C.F.R. § 3.155 for filing a claim for VA benefits, yet the Veteran has still not done so. The Board reiterates to the Veteran that if he wishes to file a claim for the above-referenced benefits or any other VA benefits, he must do so on the appropriate form prescribed by the Secretary. Although all the evidence of record has been thoroughly reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). The analysis in this decision focuses on what the evidence shows or fails to show with respect to the matters decided herein. The Veteran should not assume that pieces of evidence not explicitly discussed herein have been overlooked. See Allday v. Brown, 7 Vet. App. 517, 527 (1995) (finding that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). 1. Entitlement to an initial disability rating in excess of 50 percent for PTSD with major depressive disorder The Veteran’s PTSD with major depressive disorder is currently rated as 50 percent disabling. He asserts that he should be afforded a higher rating. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2017). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Psychiatric disorders, such as PTSD, are rated pursuant to the criteria under 38 C.F.R. § 4.130, Diagnostic Code 9411, General Rating Formula for Rating Mental Disorders (General Rating Formula). Under the General Rating Formula, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory, e.g., retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is assigned where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The next higher and maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. Symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Id. Instead, VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment. Id. Factual Background and Analysis The Veteran’s PTSD has been rated as 50 percent disabling since service connection became effective, March 11, 2009. Initially, and as discussed in depth more below, the Veteran suffered two strokes in 2007. As a result, he has residual neurological and cognitive defects, for which he has received several separately assigned disability ratings. Accordingly, the Veteran’s cognitive defects will not be considered in the context of his claim for an increased rating for PTSD, as they are clearly distinguishable, and because the assigned disability rating for residuals of a stroke have already considered these effects. To consider the Veteran’s cognitive functioning in the context of his claim for an increased rating for PTSD would amount to pyramiding. See 38 C.F.R. § 4.14 (2017). The record contains a December 2009 QTC examination for PTSD. The Veteran reported problems with sleep since Vietnam, indicated he felt intense rage inside, and had difficulty dealing with people. He acknowledged reexperiencing traumatic events from Vietnam. He also endorsed difficulty falling asleep, irritability, anger outbursts, and exaggerated startle response. He denied past or present history of delusions or hallucinations and denied obsessive or ritualistic tendencies. Memory for remote and recent events was fair, thought process was essentially normal, and there was no evidence of impaired judgment or impaired abstract thinking. Since returning from service, the Veteran worked at various transportation companies; he described relationship his with coworkers and superiors as “social.” He later owned and ran two transportation companies himself for nearly thirty years. The Veteran stated that he doesn’t do much now other than attend his VA appointments and volunteer at VA two or three times a week. He spends time on his computer, checks his e-mail, and works around the house. He reported he tries to help as much as he can but is limited cognitively as well as physically getting around. The Veteran indicated he was currently retired and unable to work due to physical handicap. The examiner found the Veteran’s PTSD symptoms caused occupational and social impairment with reduced reliability and productivity. The examiner found the following symptoms predominated: impaired short-term memory, impaired motivation and mood. The Veteran reported feeling frozen when encountering a different and challenging task and reported he had difficulty establishing and maintaining effective work and social relationships. A January 2010 VA mental health treatment note reflects the Veteran continued to experience intrusive symptoms of PTSD and that the physical problems he struggled with as a result of his service acts as a trigger, in addition to news about Iraq and Afghanistan. The Veteran stated his depression gradually became worse; there were some days when he does not shave or bathe, something he never did in the past. He indicated he wanted to try to work towards running a business, something he could do from his home. He further indicated he would continue volunteering, something he has found to be extremely helpful. He acknowledged difficulty communicating with his wife since his recent stroke and asked if he could bring her to his next appointment. In April and May 2010, the Veteran attended two marital counseling sessions with his wife. December 2013 VA mental health treatment records reflect that the Veteran resumed treatment due to intimacy and health issues that were negatively affecting his marriage. His chief complaint was anxiety and depression symptoms, and he indicated his wife complained because he did not show empathy or sympathy toward her because he would change the subject when she brought up something important to her. He acknowledged difficulty showing affection with his children. He further reported nightmares, flashbacks, recurring/intrusive thoughts of trauma, irritability or anger, and hypervigilance with loud noises. The Veteran indicated he woke up happy every day but experienced crying spells when discussing emotional subjects. He reported that he enjoyed relaxing at home more since retirement and that he enjoyed reading and was active in a few community organizations but preferred less responsibility now. He indicated he would go to the mall or the movies but would often feel tense and edgy. The Veteran participated in PTSD treatment in 2014; he reported continuing to struggle with PTSD symptoms but found the recovery group helpful. At times, he reported his irritability was worsening, that he felt he lacked empathy for others, and expressed interest in pursuing an anger management course. At other times, he indicated he felt calmer, more patient, and less reactive. The Veteran resumed mental health treatment in September 2016; he reported recent stress due to his health issues and challenges with coping with memory issues since his stroke. He indicated his PTDS symptoms remained persistent yet stable. He described intrusive memories, emotional numbing, decreased interest, and irritability, which caused stress in his marriage. July 2017 VA mental health notes reflect the Veteran felt his PTSD symptoms remained persistent, but that he was doing better than he was prior to treatment in 2014. The Veteran endorsed challenges in his marriage due to his physical and cognitive issues as a result of his stroke. An August 2017 VA mental health telephone encounter note reflects the Veteran endorsed increased intrusive memories, sleep difficulty, strong emotions, and difficulty winding down over the past several days. The note reflects the Veteran most recently participated in a PTSD program in 2014. In an October 2017 VA mental health appointment, the Veteran reported that intrusive thoughts had gradually subsided since his last visit. At a November 2017 VA mental health appointment, the Veteran reported that intrusive memories had decreased since his last visit and discussed how changes in thinking and behavior have helped. The Veteran also discussed how his physical challenges had resulted in his wife assuming caregiving responsibilities, which increased strain on their relationship. At December 2017 VA mental health appointments, the Veteran reported increased anger and that he gets frustrated with people walking in front of him in his motorized wheel chair, which bothers his wife. He indicated he did not have any coping strategies and that he normally “explodes.” He endorsed difficulty managing his anger and irritability, which affects relationships in his life. He denied depression symptoms, anxiety, or panic and indicated his PTSD treatment had been very helpful and denied PTSD related symptoms of difficulties. He acknowledged he had been married to his second wife for fifteen years and his relationship with his children and grandchildren is ok. He further indicated he was averaging nine hours of sleep a night and denied suicidal or homicidal ideations. Regarding social activities, the Veteran reported going anywhere with his wife, and going on annual beach and Disney vacations. VA treatment records reflect the Veteran attended anger management group psychotherapy from March to May 2018. An April 2018 VA phone call record indicates the Veteran found this group helpful thus far. At an April 2018 VA PTSD examination, the Veteran reported continued problems with anger, especially “when people cut [him] off and don’t see [his] cane.” The examiner noted the Veteran’s grooming and hygiene were good and that he walked with the assistance of a cane due to a stroke. Thought processes were logical, the Veteran was oriented in all spheres, and memory functions were intact. He denied suicidal or homicidal ideations. The Veteran stated he had been married to his current wife for 15 years and that this is his second marriage; he and his wife go out to dinner and to the movies. He reported being bothered by loud noises and avoiding events with fireworks. Admirably, the Veteran reported volunteering at his local VA Medical Center and participating in an online stroke support group. He stated he recently cut off communication with his older brother due to a history of verbal and emotional abuse; he acknowledged a strained relationship with his daughter from his first marriage because of the divorce. He reported that he was not as social as he used to be and avoided large crowds. The Veteran indicated he worked until he had “two strokes within ten days of each other in 2007.” He previously worked in the transportation field for forty five years. Problems with authority figures were endorsed as the Veteran reported he did not like “taking others from others and that’s why [he] ran [his] own business. The examiner noted that while the Veteran stated he occasionally had difficulty focusing on tasks and his wife reminded him what he needs to do, there was no evidence of distractibility during the examination and the Veteran was able to respond to questions without difficulty. The examiner described the Veteran’s symptoms of PTSD as depressed mood, anxiety, and disturbances of motivation and mood and found the occupational and social impairment due to his PTSD was best described as manifested by reduced reliability and productivity. In support of his claim, the Veteran submitted a June 2015 statement. He indicated that his PTSD caused his first marriage of 32 years to fail, resulting in the loss of his home. He also alleged his PTSD caused him to lose his three businesses and has resulted in his adult children being estranged from him. Following a thorough review of the record, the Board finds that a disability rating in excess of 50 percent for PTSD is not warranted. The Veteran’s PTSD is best described as manifested by occupational and social impairment with reduced reliability and productivity. There is no evidence throughout the appeal period that the Veteran’s PTSD has caused occupational and social impairment with deficiencies in most areas or caused total occupational and social impairment. While the Veteran has experienced depression, anxiety, and irritability, these symptoms have not caused violence or significant interference with the Veteran’s daily routines. He is still able to enjoy relaxing around the house, reading, working around the house, spending time on the computer, vacations with his wife, and admirably volunteering with VA. Even though he endorsed feeling tense and edgy when going to the mall or movies, he was still able to do so. Although the Veteran acknowledged that there were some days he did not bathe or shave, something he did not used to do, the Board does not find this rises to the level of neglecting one’s personal hygiene. Moreover, the Board acknowledges that the Veteran’s relationships are strained with his family due to his mental health symptoms, yet he is not completely unable to maintain effective relationships. He continues to be married to his wife, whom he has been married to for over fifteen years, and he has acknowledged that she has been supportive in assisting him in dealing with his symptoms. The evidence does not reflect persistent delusions or hallucinations, grossly inappropriate behavior, or that the Veteran is a danger to himself or others. As discussed above, the Veteran’s cognitive deficits have been attributed to his service-connected residuals of a stroke, and have been appropriately considered under the disability rating for that disorder. The Board does not doubt that the Veteran faces daily challenges in dealing with his mental health symptoms and understands that these symptoms have had adverse effects on his life. The Board is grateful for the Veteran’s service to our country, particularly during a very difficult time in our country’s history. Notwithstanding the foregoing, the assigned 50 percent rating is recognition that the Veteran experiences difficulties in functioning, and absent evidence of psychiatric symptoms causing a more severe level of occupational and social impairment, a higher rating is not warranted. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (holding that a less than total disability rating in itself is recognition that occupational capabilities are impaired). Based on the foregoing, the Board finds the Veteran’s PTSD with major depressive disorder is best described as manifested by occupational and social impairment resulting in reduced reliability and productivity. Accordingly, a disability rating in excess of 50 percent is not warranted. The Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against a rating in excess of 50 percent, and therefore, it is not applicable. 38 U.S.C. § 5107(b) (2012); see Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). 2. Entitlement to TDIU 3. Entitlement to SMC In the Veteran’s claim for entitlement to TDIU, which was received on January 11, 2008, he claimed he was unemployable due to his coronary artery disease and diabetes mellitus, type II. In adjudicating the Veteran’s claim, the Board will consider all of the Veteran’s service-connected disabilities and the effect on the Veteran’s functioning beginning January 11, 2007, one year prior to the date of the receipt of the Veteran’s claim. See 38 C.F.R. § 3.400(o) (2017). Legal Criteria Total disability ratings will be assigned “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. § 3.340(a). TDIU may be assigned to a veteran who meets certain disability percentage thresholds and is “unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities.” 38 C.F.R. § 4.16(a). An award of TDIU does not require a showing of 100 percent unemployability. See Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). However, an award of TDIU requires that the claimant show an inability to undertake substantially gainful employment as a result of a service-connected disability or disabilities. 38 C.F.R. § 4.16(b). The central inquiry is “whether [a] veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Unlike the regular disability Rating Schedule, which is based on the average work-related impairment caused by a disability, “entitlement to TDIU is based on an individual’s particular circumstances.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in determining whether unemployability exists, consideration must be given to a veteran’s level of education, special training, and previous work experience, but not to age or to any impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (holding that level of education is a factor in deciding employability); Friscia v. Brown, 7 Vet. App. 294, 295-97 (1994) (considering a veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532, 534 (1994) (considering a veteran’s eighth-grade education and sole occupation as a farmer); Moore (Robert) v. Derwinski, 1 Vet. App. 356, 357 (1991) (considering a veteran’s master’s degree in education and his part-time work as a tutor). A total disability rating may be assigned when the schedular rating is less than total, where, if there is only one disability, the disability is rated at 60 percent or more, or where, if there are two or more disabilities, at least one disability is rated 40 percent or more and there is sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Where the percentage requirements for schedular TDIU are not met, TDIU may nevertheless be assigned on an extra-schedular basis when a veteran is unable to secure or follow a substantially gainful occupation as a result of his or her service-connected disability or disabilities; however, the Board is precluded from assigning extra-schedular TDIU in the first instance. See 38 C.F.R. § 4.16(b); see also Bowling v. Principi, 15 Vet. App. 1, 10 (2001). VA has a well-established duty to maximize a claimant’s benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993). This duty to maximize benefits requires VA to assess all of a claimant’s disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008) (finding that SMC “benefits are to be accorded when a Veteran becomes eligible without need for a separate claim”). SMC benefits by reason of being housebound are payable if the Veteran has a single permanent disability rated 100 percent disabling, and has either (1) additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) is “permanently housebound” by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The disability or disabilities independently ratable at 60 percent or more must be separate and distinct from the 100 percent service-connected disability and must involve different anatomical segments or bodily systems. 38 C.F.R. § 3.350(i)(1). The Court of Appeals for Veterans Claims (Court) has held that a separate award TDIU predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability or disabilities separately rated at 60 percent or more could warrant SMC under 38 U.S.C. § 1114(s). Bradley, 22 Vet. App. at 293-94. Thus, the Court reasoned, it might benefit the Veteran to retain or obtain entitlement to TDIU even where a 100 percent schedular rating also has been granted. Id. Indeed, as noted in Bradley, VA must consider a TDIU claim despite the existence of a schedular total rating and award SMC under 38 U.S.C. § 1114(s) if VA finds the separate disability supports entitlement to TDIU independent of the other 60 percent disability rating. See id. Factual Background and Analysis Beginning January 11, 2007, and prior to June 14, 2007, the Board finds the evidence does not reflect that the Veteran’s service-connected disabilities prevented him from obtaining or maintaining any gainful occupation for which he otherwise would be qualified for by virtue of his education and experience. See 38 C.F.R. § 4.16. During this time, Veteran’s service-connected disabilities included arteriosclerosis coronary artery disease (rated as 60 percent disabling), diabetes mellitus, type II (rated as 40 percent disabling), erectile dysfunction (rated as 20 percent disabling), left lower extremity peripheral neuropathy (rated as 10 percent disabling), and right lower extremity peripheral neuropathy (rated as 10 percent disabling). During this period, there are no medical records for any treatment for any of the Veteran’s service-connected disabilities and there is no evidence that he was unable to work due to his service-connected disabilities. Further, the Veteran has not submitted any lay statements indicating why he believes TDIU is warranted during this time. Absent any evidence in support of his claim, prior to June 14, 2007, entitlement to TDIU must be denied. Beginning June 14, 2007, the Board finds that the evidence reflects his service-connected residuals of a stroke alone (both neurological and cognitive deficits) have rendered him unable to obtain or maintain a gainful occupation for which he otherwise would be qualified for by virtue of his education and experience. See 38 C.F.R. § 4.16. During this time, the Veteran’s service-connected disabilities include: arteriosclerosis coronary artery disease (rated as 60 percent disabling); status post ischemic stroke (rated as 100 percent disabling prior to February 1, 2008, and as noncompensable thereafter); PTSD (rated as 50 percent disabling beginning March 11, 2009); diabetes mellitus, type II (rated as 40 percent disabling); right lower extremity peripheral neuropathy (rated as 10 percent disabling prior to January 11, 2008, and as 20 percent disabling thereafter); left lower extremity peripheral neuropathy (rated as 10 percent disabling prior to January 11, 2008, and as 20 percent disabling thereafter); right upper extremity hemiparesis (rated as 20 percent disabling beginning February 1, 2008); left upper extremity hemiparesis (rated as 20 percent disabling beginning February 1, 2008); left sided facial hemiparesis (rated as 10 percent disabling beginning February 1, 2008); gastroesophageal reflux disease (rated as 10 percent disabling from May 15, 2009); and erectile dysfunction (rated as 20 percent disabling). The Veteran suffered two strokes in June 2007, the first on June 14, 2007, resulting in cognitive and neurological deficits. A July 2007 rehabilitation plan included physical, occupational, speech, and recreational therapy. The focus on this therapy was on improving lower and upper extremity strength and endurance, particularly the left upper extremity. The record contains a June 2008 letter from R. W., M.D., the physician who treated the Veteran for his strokes, and which describes the Veteran’s history of strokes and resulting deficits. The letter indicates that the Veteran had, in a very short period of time, two strokes, the second of which was devastating. The Veteran recovered better than expected; however, Dr. R. W. emphasized that his recovery was not that of normal function, simply that it was better than physicians had expected. Dr. R. W. noted that the Veteran was left with functional deficits including residual hemiparesis, clear cognitive difficulties in terms of executive function and overall impairment of stamina. Dr. R. W. opined that the Veteran’s deficits were unlikely to improve to any great degree and that the Veteran was not employable now or any time in the future. Several VA treatment records reflect that the Veteran’s blood sugar has been uncontrolled, which has, at times, lead to hypoglycemia. Moreover, the Veteran’s memory has declined from the stroke, resulting in his inability to remember to take his insulin. He has attended physical therapy and occupational therapy on several occasions to improve fine motor skills and neurological effects of the stroke to the left side of his body. He suffers from bilateral lower extremity peripheral neuropathy which further impairs his ability to be mobile. The Veteran has experienced falls due to his service-connected disabilities on several occasions. A May 2010 VA speech pathology progress note indicates that the Veteran reported his attention, organization, and recall have all declined since his previous speech therapy sessions ended. A February 2011 VA primary care note reflects the Veteran sought treatment falls where his left leg suddenly gives out. The examiner noted this is the same side affected by his hemorrhagic stroke years ago and indicated the falls were likely related to osteoarthritis and residual deficits from the stroke. A March 2011 VA neurology consultation reflects the Veteran developed tremors in his left arm over the past month, which occurred for a few seconds every two to three weeks. The examiner noted the Veteran’s gait had not changed, but that his stroke resulted in left sided weakness, and his leg could give out. Although a February 2013 VA treatment note reflects the Veteran was walking two to four miles a day at that time, his ability to ambulate began to decrease more in the following years. A July 2014 VA aid and attendance examination reflects the Veteran experienced mild memory loss, imbalance which occasionally affects his ability to ambulate, and mild to moderate impairment of his left upper extremity due to his stroke. A September 2014 VA neurology note reflects the Veteran continued to experience weakness, cognitive issues, and occasional short-term memory loss. VA treatment records dated 2015 reflect the Veteran experienced difficulty walking due to lower leg heaviness, abnormal/decreased sensation to his feet, and difficulty with stamina and energy level. VA physicians indicated this is due to his poorly controlled diabetes, peripheral neuropathy of the bilateral lower extremities, and residuals of his stroke. A June 2016 VA occupational therapy note reflects that the examiner determined a stair glide was medically necessary. In March 2017 the Veteran reported less physical activity and that his ability to walk had decreased significantly. A July 2017 VA treatment note indicates the Veteran felt his memory issues had gotten worse; notably, several treatment records throughout the appeal indicate that the Veteran has had difficulty remembering to take his medication since his strokes. An August 2017 VA neurology note reflects the Veteran reported weakness and loss of balance, with several falls in the past year, the last one being in May. He recently engaged in physical and occupational therapy in order to improve his fine motor skills, which have diminished following his stroke. That same month, the Veteran participated in neuropsychological objective testing and attended a feedback portion of the evaluation with a synopsis of test results and recommendations. The examiner noted the Veteran put forth sufficient effort during testing, as evidenced by his performances on select measures of effort validity, and that therefore the following test interpretations are believed to be an accurate representation of his neurocognitive functioning at the time of the evaluation. The examiner informed the Veteran and his wife that based on clinical interview with them, behavioral observations, and neuropsychological test findings, the Veteran’s profile of neurocognitive functioning was most consistent with mild neurocognitive disorder. January and February 2018 VA neurology notes reflect the Veteran had been using an electric chair due to poor stamina and balance for the past three years. He was able to use a cane or walker for shorter distances (approximately two blocks). In a June 2015 statement in support of his claim, the Veteran indicated that his stroke resulted in cognitive issues as well as left sided weakness, which has caused him to fall at times. He stated his mobility issues caused him great difficulty and requested authorization for a power scooter to help him get around. In an August 2018 statement, the Veteran indicated that his heart condition precluded him from lifting and straining to pick up and load/unload his wheelchair from his vehicle. He indicated he was unstable since his strokes and that his diabetic neuropathy causes him to feel unbalanced. He stated his wife does almost everything for him and around the house, including preparing his food, assisting him with dressing himself, ordering and sorting his medication, and ensuring he takes his insulin and medication, otherwise he would forget. Although the Board is not obligated to explain the specific types of jobs the Veteran would be able to perform or the availability of work, it must consider all functional impairment resulting from his service-connected disabilities and how it would impact his ability to work. See Smith v. Shinseki, 647 F.3d 1380, 1384 (2011). Considering the Veteran’s physical limitations, the Board acknowledges that a physically demanding job would not be feasible for the Veteran. Moreover, given his cognitive deficits as a result of his stroke, maintaining focus would prove to be difficult in any sedentary job. Further, given that the Veteran has not worked at all during the appeal period, the Board recognizes it is difficult to assess how his service-connected disabilities would affect his ability to work in a substantially gainful occupation during this time. (CONTINUED ON NEXT PAGE) Based on the foregoing, the Board finds that based solely on his service-connected residuals of a stroke (neurological and cognitive effects), and with consideration of his education, experience and work history, that he has been unable to obtain or maintain substantially gainful employment since June 14, 2007. Given that the Board has granted entitlement to TDIU effective June 14, 2007, based solely on the Veteran’s residuals of a stroke, and given that during that time he has also had independently rated disabilities at 60 percent or more, the Board is also awarding SMC at the housebound rate, beginning June 14, 2007. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). VA’s Duties to Notify and Assist With respect to the Veteran’s claims for an increased rating for PTSD with major depressive disorder, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). VA’s duty to notify was satisfied by a letter dated April and June 2009. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The duty to assist the Veteran has been satisfied in this case. The Agency of Original Jurisdiction (AOJ) has obtained the Veteran’s service treatment records, VA treatment records, and private treatment records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Moreover, the Veteran was afforded a recent VA examination in October 2015 to assess the current severity of his psychiatric disability. (CONTINUED ON NEXT PAGE) The Veteran has not identified any additional, existing evidence that could be obtained to substantiate his claim. The Board is also unaware of any such evidence. Accordingly, the Board finds that VA has satisfied its duty to assist the Veteran. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jessica O'Connell, Associate Counsel