Citation Nr: 20005485 Decision Date: 01/23/20 Archive Date: 01/22/20 DOCKET NO. 09-27 276 DATE: January 23, 2020 REMANDED Entitlement to service connection for the cause of the Veteran’s death is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1946 to June 1948 and from September 1950 to January 1954. He died in February 2008 and the appellant has filed this claim is his surviving spouse. In September 2017, the Board denied the appellant’s claim, after which she appealed to the United States Court of Appeals for Veterans Claims (Court). In September 2018, VA and the appellant (the parties) filed a Joint Motion for Remand (JMR), which was granted by the Court that same month. As discussed below, the Board finds that additional development is required. Entitlement to service connection for the cause of the Veteran’s death is remanded. At the time of his death, the Veteran was service-connected for PTSD, rated as 100 percent disabling, and residuals of a right frozen foot, rated as 30 percent disabling. The appellant, through her attorney, has raised two theories of entitlement to service connection for the Veteran’s cause of death. First, that the Veteran’s dementia resulted from alcoholism that was secondary to his service-connected PTSD, which contributed to the Veteran’s fall. Second, she alleges that medication used to treat the Veteran’s service-connected PTSD led to the Veteran’s fall, which caused his death. Given the possibility that the psychotropic medication the Veteran was prescribed to treat nightmares associated with his service-connected PTSD contributed to his fall and thereby his death, along with the possibility that alcoholism secondary to PTSD resulted in dementia that contributed to the Veteran’s death, the matter is remanded to obtain a VA medical opinion on these matters The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from an appropriate examiner regarding the cause of the Veteran’s death. The examiner is informed of the following facts: • The Veteran served on active duty from January 1946 to June 1948 and from September 1950 to January 1954 and engaged in combat during the Korean Conflict. • During the Veteran’s lifetime, he was service connected for posttraumatic stress disorder (PTSD), which was rated as 100 percent disabling as of October 2007, and residuals of a right frozen foot, which was rated as 30 percent disabling as of October 2007. • The Veteran died in February 2008 after sustaining a fall in January 2008, wherein he fractured his left hip. He was 79 years old. • The Veteran’s certificate of death lists complications of a left hip fracture as the immediate cause of death. Hypertension, coronary artery disease, and renal failure were listed as other significant conditions contributing to death but not resulting in the underlying cause. See VBMS entry with document type “Death Certificate,” receipt date 02/14/2008. • The Veteran’s surviving spouse has submitted a claim to VA, where she alleges that the cause of the Veteran’s death was either due to the Veteran’s service-connected PTSD and/or due to medication, used to treat the Veteran’s service-connected PTSD, specifically, quetiapine. She states that quetiapine has a side effect of dizziness, which contributed to the Veteran’s fall that led to his death. As to PTSD causing the Veteran’s death, she alleges that the Veteran abused alcohol over the years as a result of his PTSD and that it caused him to develop dementia, which diagnosis contributed to the Veteran’s death due to the Veteran’s lack of cognitive functioning. • A May 2004 PTSD evaluation documents that the Veteran had a long history of “self-medication with alcohol.” It was documented that he had stopped drinking “about three years ago,” which would have been in approximately 2001. See VBMS entry with document type, “VA Examination,” receipt date 05/13/2004.” • The Veteran was seen in October 2007 with complaints of panic feelings, flashbacks, and persistent thoughts. It was noted that he had been taking Bupropion for two months and had run out of it three weeks prior. It was noted that the Veteran and his wife had moved from Texas to Florida, where one of their daughters lived. The Veteran reported nightmares associated with night sweats that occurred three times per week. The Veteran’s wife said she did not want to sleep with the Veteran because he was combative in his sleep and had hit her in the past. The Veteran denied intrusive thoughts about his military experiences, but reported episodes of depressed mood. He reported he had problems with recent and intermediate memory for the last two years and had problems with organization and planning. information for purposes of understanding. The examiner described the Veteran as alert, oriented times three, cooperative, casually attired and adequately groomed. His speech was fluent with normal rate and volume, he maintained good eye contact, and his mood was dysphoric with full range and mood-congruent affect. Thought processes were logical and relevant, and thought content was without psychotic features. The Veteran denied suicidal or homicidal ideation and auditory or visual hallucinations. The examiner noted that recent and intermediate memory were impaired. There was no psychomotor retardation/agitation, and insight and judgment were adequate. The examiner diagnosed PTSD and dementia. The examiner noted that the Veteran would be restarted on Bupropion and started on Aricept for memory. See VBMS entry with document type, “CAPRI,” receipt date 1/28/2008, at pp. 13-15. • For background purposes, there is notation in this October 2007 medical record of the Veteran having a left leg amputation. The Veteran had an above-the-knee left leg amputation in 1993 due to disabilities that are not related to service or a service-connected disability (peripheral vascular disease and diabetes mellitus). The Veteran is service connected for a disability involving his right foot only, as the service treatment records document that he sustained third degree frostbite to the right great toe. There was no left foot involvement. The Veteran also has a long history of smoking. A February 2008 record shows that the Veteran smoked for 65 years. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #4 in the Subject line, receipt date 11/16/2016, at p. 13. • The Veteran was next seen at VA in November 2007, and the examiner noted that he was last there in October 2007 and restarted on Bupropion SA and Aricept had been added for memory. The Veteran’s daughter told the examiner that she stopped giving the Veteran Aricept because he was more withdrawn and confused. The Veteran’s wife reported that the Veteran would wake up anxious and sweating, and that he saw insects and people that were not real. The Veteran’s wife and daughter denied that the Veteran was having any violent or wandering behavior. The Veteran’s PTSD symptoms were reported, which symptoms are similar to those described in October 2007 with problems with recent and intermediate memory. The examiner described the Veteran as alert, active, oriented times three, cooperative, casually attired and adequately groomed, on wheelchair with left leg amputation. There were no abnormal movements. His speech was fluent with normal rate and volume, answered questions without elaboration, maintained good eye contact, and his mood was dysphoric with full range and mood-congruent affect. Thought processes were logical and relevant, and thought content was without psychotic features. The Veteran denied suicidal or homicidal ideation or auditory or visual hallucinations. Recent and intermediate memory were noted to be impaired. Attention and concentration were intact. There was no psychomotor retardation/agitation. Insight and judgment were documented to be adequate. The examiner diagnosed PTSD and dementia. She noted that Veteran was unable to tolerate Aricept due to side effects and that she would add Quetiapine to help with hallucinations and nightmares. The examiner wrote to start the Veteran on Quetiapine, 25 mg for 7 days and then 50 mg for psychotic symptoms. See VBMS entry with document type “VA Examination,” receipt date 01/28/2008, a pp. 8-9. • The Veteran was next seen at VA on January 4, 2008. The examiner noted that Quetiapine had been added to the Veteran’s medications to help with visual hallucinations. The Veteran reported sleeping better, but continued to report visual hallucinations. The Veteran’s daughter reported that the Veteran had episodes of getting more disorganized and agitated, but was doing better with Quetiapine. The Veteran reported he continued to have nightmares a few times a week, which were associated with night sweats. The examiner described the Veteran as alert, oriented times three, cooperative, casually attired, and adequately groomed. Speech was fluent with normal rate and volume. The Veteran answered questions without elaboration. He maintained good eye contact. Thought processes were logical and relevant. Thought content was without psychotic features. The Veteran denied suicidal or homicidal ideation or auditory or visual hallucinations. The examiner described the Veteran’s recent and intermediate memory as impaired. Attention and concentration were intact. There was no psychomotor retardation/agitation. Insight and judgment were adequate. The examiner diagnosed PTSD and dementia. She noted that the Veteran had shown some improvement of sleep with Quetiapine, but that he continued to have visual hallucinations and episode of disorganized behavior and agitation. She added she would increase Quetiapine to help with “it.” See VBMS entry with document type, “Medical Treatment Record – Government Facility,” receipt date 09/21/2016. • The Veteran underwent a VA examination on January 10, 2008 in the morning. The Veteran’s wife and daughter were at the examination with him. The daughter reported that the Veteran was having visual hallucinations of people, bugs, and birds that were supposedly around. The Veteran’s daughter reported that, overnight, the Veteran had episodes in which he had apparent nightmares in which he reacted violently. She also reported he would have violent reactions when he was awake. The Veteran’s daughter and wife described the Veteran as unpredictable and that while he may appear calm, he would suddenly lose control and become aggressive. They noted the Veteran used gloves to handle his wheelchair. The examiner noted that there was a significant chronic history of alcohol dependence throughout the Veteran’s life and that he had stopped drinking three to four years ago. At the time of the examination, the Veteran knew he had seven children, but he could not remember the names or ages of the children or the oldest or youngest either. The examiner described the Veteran’s speech as impoverished, hesitant, slow, slurred, mumbled, irrelevant. The Veteran was suspicious, irritable, and apathetic toward the examiner. His affect was constricted, and his mood was dysphoric and labile. The examiner wrote that the Veteran was only marginally oriented. The examiner stated the Veteran was aware of the city he was in, but not the state and not aware of his own address. The examiner wrote the Veteran’s remote and recent memory were moderately impaired. The examiner diagnosed PTSD, alcohol dependence in full sustained remission, and alcohol-induced persisting dementia vs. dementia NOS. The examiner noted that the Veteran had a long history of alcoholism that had probably caused some of his dementing process. He added that the extent to which his use of alcohol vs. his PTSD had aggravated his dementing process could not be determined with accuracy. He noted that it may be the case that dementing process may stem from chronic alcoholism secondary to PTSD. The examiner noted that the Veteran had no history of drug abuse. See VBMS entry with document type, “VA Examination,” receipt date 01/10/2008, at pp. 2-8. • Within the above document, there is a list of medications that were deemed to be “Active.” The Veteran was taking (1) aspirin, (2) Bupropion, (3) Clotrimazole, (4) Glipizide, (5) Insulin NPH Human, (6) Losartan, (7) Nitroglycerin, (8) Quetiapine, (9) Ranitidine, (10) Simvastatin, and (11) Terazosin. (Also listed were test strips for diabetes mellitus.) See VBMS entry with document type, “VA Examination,” receipt date 01/10/2008, at p. 12. • In looking up the side effects for each of these medications, the Board found “dizziness” was a side effect for (1) Bupropion, (2) Glipizide, (3) Insulin NPH Human, (4) Losartan, (5) Nitroglycerin, (6) Quetiapine, (7) Ranitidine, and (8) Terazosin. • On January 10, 2008 at 1:00pm, the Veteran underwent a VA examination in connection with his residuals of right frozen foot. The Veteran told the examiner that he was wheelchair bound and unable to use a prosthesis because of poor balance from the combined cold injury and diabetic peripheral neuropathy in the remaining right foot and leg. The examiner noted that the Veteran’s daughter and wife reported that the Veteran’s foot was of much better color since he stopped smoking in September 2007. The examiner wrote that the Veteran had decreased sensation in the right lower extremity and foot, and muscle strength was 5. See VBMS entry with document type, “VA Examination,” receipt date 01/10/2008, at pp. 10 16. • On January 10, 2008, in the evening, the Veteran was admitted to a private facility, where it was noted that he had fallen on Sunday and broke his left hip. The medical record shows, “Fell Sunday.” The fall would have happened on January 6, 2008 (January 6, 2008 was on Sunday). See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #12 in the Subject line, receipt date 11/16/2016, at p. 4. • A January 11, 2008, “physician’s progress notes” shows that the examiner noted that the Veteran had fallen and injured his left hip. The examiner documented the Veteran was a diabetic, had peripheral vascular disease, and history of myocardial infection. The examiner wrote, “Daughter states she isn’t sure how [the Veteran] fell.” See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #3 in the Subject line, receipt date 11/16/2016, at p. 8. • The Veteran was admitted that day with the following diagnoses: (1) intertrochanteric fracture, (2) acute pancreatitis, (3) bladder/urethra injury, (4) chronic airway obstruction, (5) hematuria, (6) ulcer of the foot, (7) hyperlipidemia, (8) old myocardial infarct, (9) diabetes mellitus, (10) tobacco use disorder, (11) anemia, (12) peripheral vascular disease, (13) hypertension, (14) esophageal reflux, (15) urinary catheterization, (16) fall, (17) long-term use of insulin, (18) history of prostatic malignancy, and (19) above-the-knee amputation. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #12 in the Subject line, receipt date 11/16/2016, at p. 11. • In a separate January 11, 2008 “History and Physical” document, it noted that the Veteran had been in the office the day before, at which time, he had an outpatient x-ray showing an intertrochanteric fracture. The examiner documented that the Veteran was a left high amputee “secondary to probably his diabetes.” The examiner performed a review of systems and noted that the Veteran denied chest pain, shortness of breath, and asthma, but admitted he continued to smoke. The examiner noted that the Veteran had been on Wellbutrin, but that this did not seem to curb his smoking. The examiner wrote that the Veteran had peripheral neuropathy in his right leg secondary to diabetes and that the Veteran’s eyesight was “okay.” The examiner described the Veteran as oriented to time and place, but noted that the Veteran was having issues with his memory. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #12 in the Subject line, receipt date 11/16/2016, at pp. 18-19. • In the above-described January 11, 2008 medical record, 12 medications were listed, which differed slightly from the list in the January 10, 2008 VA treatment record described above. This document listed the Veteran’s present medications as (1) aspirin, (2) Buspar, (3) Codeine tablets at bedtime for pain, (4) Aricept, (5) Glipizide, (6) Losartan, (7) Nitroglycerin spray, (8) Zantac, (9) Zocor, (10) Hytrin, (11) NPH insulin, and (12) Lamisil. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #12 in the Subject line, receipt date 11/16/2016, at p. 18. • In looking up the side effects for the medication listed in the private medical record, described above, the Board found “dizziness” was a side effect for (1) Buspar, (2) Codeine, (3) Aricept, (4) Glipizide, (5) Losartan, (6) Nitroglycerin, (7) Zantac, (8) Hytrin, and (9) NPH insulin. • When the Veteran was admitted on January 11, 2008, the examiner wrote that the Veteran moved all extremities, communicated effectively, was clear, facial symmetry was noted, recent and remote memory were intact, thought processes were intact and logical and appropriate. The Veteran was coherent and relevant, and there was, “No complaint of dizziness/vertigo; syncope/fainting.” See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #6 in the Subject line, receipt date 11/16/2016, at p. 17. • The Veteran remained at the private facility from January 11, 2008 to January 19, 2008. The final diagnoses listed in the hospitalization summary were (1) left intertrochanteric fracture, (2) hematuria, (3) ulcer of the right foot and fifth toe secondary to peripheral vascular disease, (4) hyperlipidemia, (5) old myocardial infarction, (6) diabetes mellitus, (7) history of nicotine use, (8) hypertension, and (9) prostate cancer. The examiner noted that the Veteran progressed well and was a little bit confused at times but overall seemed to do pretty well. He was treated for a urinary tract infection and was restrained so that he would not pull out his Foley catheter a second time. He was sent to a different facility for rehabilitation. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #12 in the Subject line, receipt date 11/16/2016, at pp. 12-14. • The next documentation of treatment for the Veteran was on February 12, 2008, when the Veteran was seen at VA. The examiner noted that the Veteran had been discharged from a private facility on February 6, 2008, following treatment for the left hip fracture. The examiner wrote that the Veteran had been treated conservatively, as he had a left above-the-knee amputation years back. The Veteran’s daughter reported that the Veteran was not eating or drinking due to vomiting, diarrhea, loose stools for two weeks and abdominal pain as well. The Veteran’s daughter stated that the Veteran had lost 30 to 35 pounds over a period of weeks. The VA examiner recommended that the Veteran be admitted to the hospital. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #1 in the Subject line, receipt date 11/16/2016, at p. 12. • The Veteran was admitted to a private facility on February 12, 2008 with complaints of diarrhea, abdominal pain, and vomiting with dehydration. He died two days later. In the Death Summary, the examiner wrote that the Veteran had been placed in intravenous fluids and that in spite of the aggressive antibiotics and IV fluid, the Veteran’s condition did not improve. His condition continued to deteriorate until the Veteran expired. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #1 in the Subject line, receipt date 11/16/2016, at pp. 14 15. • In attempting to understand the cause of the Veteran’s death, VA sought a medical opinion from a VA physician. The examiner found that the Veteran’s service-connected disabilities did not cause or contribute to the Veteran’s death. In providing an explanation for this conclusion, the examiner wrote that the Veteran had a left hip fracture from a fall while at home and that he was at “an extremely high risk for falls.” He added that the Veteran had dementia and nighttime agitation and organization and was on medication for both symptoms. He wrote that the Veteran was on Terazosin for prostatic disease, which dizziness and hypotension were known side effects. He wrote that the Veteran had severe anemia that was documented on initial admission in January 2008, which, by itself is “an extremely high risk for falls.” He also noted that the Veteran had a left above-the-knee amputation, which, by itself, had a high risk for falls. The examiner added that with elderly individuals, falls were common, and that the incidence of falls increases with age. He wrote that people who were over 80 years of age had a 50 percent risk of falls. He added that the risk of falls, such as age, cognitive impairment, psychotropic drug use, dizziness, and anemia were all high risk factors. He also wrote that postural hypotension and dizziness were also risk factors. He then wrote, “Higher risk of falls and hip fractures are associated with cognitive impairment that is moderate or mild. Antipsychotics increased the likelihood of falling.” See VBMS entry with document type “VA Examination,” receipt date 05/22/2017, at pp. 1-3. • In May 2019, the Veteran’s wife submitted a “neuropsychological evaluation,” wherein the licensed psychologist, Dr. Damond Logsdon, determined that that the Veteran’s diagnosis of dementia was at least as likely as not to be due to the Veteran’s alcohol dependence, which dependence was a form of self-medication for the Veteran’s PTSD. Dr. Logsdon found that the Veteran’s service-connected PTSD symptoms of hallucinations and agitation directly led to the prescription of quetiapine and at least as likely as not the fall that ended his life. Dr. Logsdon noted that the Veteran had never fallen to the point of seriously injuring himself prior to the prescription of quetiapine and that within four months of being prescribed this medication, he experienced a fall that led to his death. Dr. Logsdon concluded that it was his opinion that it was at least as likely as not that the Veteran’s cognitive impairment from his service-connected psychiatric disability and the medication used to treat this condition at least as likely as not caused the Veteran to fall, which led to his death. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 05/17/2019, at pp. 2-8. • On page 8 of the above document, Dr. Logsdon wrote, “On the day [the Veteran] fell and fractured his hip, he was disoriented and attempting to stand to change the channel on the television despite having a remote control to do so.” It appears that Dr. Logsdon obtained that information from a phone call he had in April 2019 with the Veteran’s wife. However, it was documented in the contemporaneous January 11, 2008 admission that the Veteran’s daughter did not know how the Veteran fell, which leads the Board to conclude that no one saw him fall. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” with #3 in the Subject line, receipt date 11/16/2016, at p. 8 (“Daughter states she isn’t sure how [the Veteran] fell.”). How the Veteran fell was not documented in the January 2008 or February 2008 treatment records. Also, the Veteran was wheelchair bound and was unable to use a prosthesis for his left lower extremity. Thus, the Board finds such fact to be of questionable reliability. • The examiner’s review of the record is NOT restricted to the evidence listed below. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked the following questions: (1) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s taking of Quetiapine caused the Veteran’s January 2008 fall? Upon what facts and medical principles do you base your opinion? (2) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s PTSD caused the Veteran’s dementia? Upon what facts and medical principles do you base your opinion? (3) If the answer to (2) is yes, is it at least as likely as not (50 percent probability or greater) that the Veteran’s dementia caused the fall that led to his death? Upon what facts and medical principles do you base your opinion? The examiner is asked to provide a rationale for each opinion given. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Chad Johnson, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.