Citation Nr: 21069158 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 18-26 477 DATE: November 17, 2021 ORDER Entitlement to service connection for dementia as secondary to service-connected ischemic heart disease is granted. Entitlement to service connection for Parkinson's Disease is denied. REMANDED Entitlement to service connection for cerebrovascular disease with associated stroke, to include as due to service-connected ischemic heart disease and/or exposure to herbicides is remanded. FINDINGS OF FACT 1. The Veteran's dementia was proximately due to his service-connected ischemic heart disease. 2. The preponderance of the evidence of record is against finding that the Veteran had Parkinson's Disease at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for dementia as secondary to service-connected ischemic heart disease are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for Parkinson's are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1964 to June 1966. He died in September 2019. The Appellant is his surviving spouse. SERVICE CONNECTION Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d); Cosman v. Principi, 3 Vet. App. 503 (1992). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists, and (2) that the current disability was either (a) proximately caused or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Entitlement to service connection for dementia as secondary to service-connected ischemic heart disease The Appellant contends that the Veteran's dementia was secondary to his service-connected ischemic heart disease or related to his conceded in-service herbicide exposure. On January 2016 VA examination, dementia was diagnosed. Private treatment records also reflected treatment for Lewy Body dementia. In a December 2016 letter, private provider Dr. A.J.B. noted that he had treated the Veteran for over 20 years and opined that it was more likely than not that the Veteran's diffuse vascular disease had affected his coronary circulation causing coronary heart disease and his dementia. Additionally, the Veteran's September 2019 death certificate reflects that the immediate cause of death was failure to thrive as a consequence of severe dementia, with coronary artery disease and mixed sleep apnea contributing to his death. In a December 2019 rating decision, service connection from the cause of the Veteran's death was granted based on the contributing cause of death of coronary artery disease (ischemic heart disease) which was service-connected at the time of the Veteran's death. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's dementia was proximately due to his service-connected ischemic heart disease. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for dementia is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. Entitlement to service connection for Parkinson's Disease During his lifetime, the Veteran claimed service connection for Parkinson's disease. The question for the Board is whether the Veteran had current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran did not have a diagnosis of Parkinson's Disease at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran initially classified his claim for service connection for dementia as Lewy Body dementia (Parkinson's) related to his in-service exposure to herbicides. The January 2016 VA examiner evaluated the Veteran and determined that, while a private neurologist arrived at a diagnosis of Lewy Body Dementia, after an initial assessment of Alzheimer's Disease, Lewy Body was not identical to Parkinson's Disease. While the neuropathology was similar, it includes cortical Lewy Bodies, which did not appear until late in Parkinson's Disease. The examiner identified that the Veteran had a cognitive decline caused by dementia. The examiner also found that the Veteran did not have the motor manifestations of Parkinson's Disease or Parkinsonism; the Veteran and his wife reported no gait problems, no balance difficulty, no rigidity and no tremors. Private and VA treatment records of record until the Veteran's September 2019 death, such treatment records do not contain a diagnosis of Parkinson's disease. While the Appellant and the Veteran believed he had a diagnosis of Parkinson's disease, they are not competent to provide a diagnosis in this case. The diagnosis and etiology of Parkinson's disease is outside the realm of common knowledge of a lay person because it involves complex medical issues that go beyond a simple and immediately observable cause-and-effect relationship. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Service connection for Parkinson's Disease is denied. REASONS FOR REMAND Entitlement to service connection for cerebrovascular disease with associated stroke, to include as due to service-connected ischemic heart disease and/or exposure to herbicides is remanded. Further clarification is necessary regarding the claim for cerebrovascular disease with associated stroke. While the Veteran's medical records reflect a history of the Veteran having a series of strokes, and an April 2015 assessment of arterial ischemic stroke, there is no records of the Veteran having a cerebrovascular accident (CVA) or transient ischemic attacks (TIA), and the January 2016 VA examiner found that the Veteran had no diagnosis of arterial ischemic stroke and a review of his medical testing did not demonstrate an arterial stroke. However, in January 2016 a private neurologist assessed occipital stroke "right," and in a December 2016 letter, private provider Dr. A.J.B. noted the Veteran had cerebrovascular disease. The record also suggests there are relevant outstanding private treatment records. In his December 2016 letter, Dr. A.J.B. identified that the Veteran had seen several private neurologists. A remand is required to allow VA to obtain authorization and request these records. The matters are REMANDED for the following action: 1. Obtain the names and addresses of all medical care providers who treated the Veteran for any stroke or neurological complaints since service. After securing the necessary release, take all appropriate action to obtain these records; to specifically include records from Dr. S in Wausau, Dr. Sp. at Ascension, and Dr. D. at University Hospital and records of any VA treatment prior to the Veteran's September 2019 death not already associated with the record. 2. After the completion of the above, obtain a medical opinion from an appropriate clinician regarding the nature and etiology of the claimed stroke. Copies of all pertinent records, including this remand, must be made available to the examiner for review. Based on the review of the record, the examiner should answer the following: (a.) Identify whether the Veteran had cerebrovascular accident (CVA), transient ischemic attacks (TIA), or a diagnosis of cerebrovascular disease prior to his September 2019 death. If the Veteran had a CVA or TIA, the examiner should identify any residuals. (b.) For the Veteran's diagnosed occipital stroke, and any identified residual of CVA or TIA or diagnosed cerebrovascular disease, is it at least as likely as not related to an in-service injury, event, or disease, to include his conceded exposure to herbicides? Why or why not? (c.) If the answer to (b) is no, is it at least as likely as not that the Veteran's diagnosed occipital stroke, and any identified residual of CVA or TIA or diagnosed cerebrovascular disease is (i) caused by or (ii) aggravated by (defined as any increase in disability) the Veteran's service-connected ischemic heart disease? Why or why not? The examiner should specifically consider and discuss as necessary the December 2016 letter from Dr. A.J.B. who opined that it was more likely than not that the Veteran's diffuse vascular disease had affected his coronary circulation causing coronary heart disease and his cerebrovascular disease with associated stroke. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 3. Confirm that the VA medical opinions provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eric Struening 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.