Citation Nr: 21070731 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-38 490 DATE: November 24, 2021 ORDER An initial evaluation in excess of 10 percent for service-connected traumatic brain injury (TBI) is denied. Special monthly compensation based on the need for aid and attendance is granted. FINDINGS OF FACT 1. The Veteran's TBI is shown to have been productive of mild memory impairment, but not symptoms warranting more than a level "1" in any category under DC 8045. 2. The evidence of record establishes that the Veteran is in need of regular aid and attendance by reason of service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for service connected TBI have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.71a, 4.124a, Diagnostic Code 8045. 2. The criteria for special monthly compensation based on the need for regular aid and attendance have been met. 38 U.S.C. §§ 1114, 1502, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In July 2017, the Veteran requested a hearing at the RO. See Veteran's appeal (VA Form 9), received in July 2017. However, in April 2020, he withdrew his request for a hearing. See Veteran's VA Form 27-0820, dated in April 2020. The Board will therefore proceed. See 38 C.F.R. § 20.702 (e). Additional medical evidence has been received following the July 2020 supplemental statement of the case that it is not accompanied by a waiver of RO review. However, the Board has determined that this evidence is not "pertinent" as defined at 38 C.F.R. § 20.1304 (c) as it merely shows cumulative and continued treatment without any findings implicating the TBI initial increased evaluation claim. Accordingly, a remand for RO consideration is not required. 1. Initial evaluation in excess of 10 percent, TBI. In June 2016, the RO granted service connection for a TBI, evaluated as 10 percent disabling, with an effective date of July 16, 2009. The Veteran has appealed the issue of entitlement to an initial evaluation in excess of 10 percent. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The RO has granted service connection for an unspecified depressive disorder, post-traumatic headaches with neck pain, tinnitus and bilateral hearing loss. The Board does not have jurisdiction over the ratings of these disabilities. See 38 U.S.C. § 7105 (a). Furthermore, these disabilities have been separately evaluated under diagnostic codes other than DC 8045, and the symptoms from these disabilities may not be considered in the evaluation of his TBI, as this would constitute pyramiding. See 38 C.F.R. §§ 4.14, 4.124a, DC 8045 Note (1); Brady v. Brown, 4 Vet. App. 203, 206 (1993). A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is in effect as of December 18, 2017. Under DC 8045, there are three main areas of dysfunction that may result from TBIs and have profound effects on functioning: cognitive (which is common in varying degrees after a TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. DC 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment should be evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Evaluation of Cognitive Impairment and Subjective Symptoms: the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of a TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, and labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100- percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. The table titled "Evaluation Of Cognitive Impairment And Other Residuals of TBI Not Otherwise Classified" provides the following evaluations: Impairment of memory, attention, concentration, executive functions are assigned numerical designations as follows: (0) No complaints of impairment of memory, attention, concentration, or executive functions; (1) A complaint of mild loss of memory (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing; (2) Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment; (3) Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; and (Total) Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. Impairment of judgment is assigned numerical designations as follows: (0) Normal; (1) Mildly impaired judgment - For complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; (2) Moderately impaired judgment - For complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions; (3) Moderately severely impaired judgment - For even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; and (Total) Severely impaired judgment - For even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. For example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities. Impairment of social interaction is assigned numerical designations as follows: (0) Social interaction is routinely appropriate; (1) Social interaction is occasionally inappropriate; (2) Social interaction is frequently inappropriate; and (3) Social interaction is inappropriate most or all of the time. Impairment of orientation is assigned numerical designations as follows: (0) Always oriented to person, time, place, and situation; (1) Occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation; (2) Occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation; (3) Often disoriented to two or more of the four aspects (person, time, place, situation) of orientation; and (Total) Consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Impairment of motor activity (with intact motor and sensory system) is assigned numerical designations as follows: (0) Motor activity normal; (1) Motor activity normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function); (2) Motor activity mildly decreased or with moderate slowing due to apraxia; (3) Motor activity moderately decreased due to apraxia; and (Total) Motor activity severely decreased due to apraxia. Impairment of visual spatial orientation is assigned numerical designations as follows: (0) Normal; (1) Mildly impaired - Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system); (2) Moderately impaired - Usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance. Has difficulty using assistive devices such as GPS; (3) Moderately severely impaired - Gets lost even in familiar surroundings, unable to use assistive devices such as GPS; and (Total) Severely impaired. May be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment. Subjective symptoms are assigned numerical designations as follows: (0) Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples are: mild or occasional headaches, mild anxiety; (1) Three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light; and (2) Three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days. Neurobehavioral effects are assigned numerical designations as follows: (0) One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. Examples of neurobehavioral effects are: Irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects; (1) One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them; (2) One or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them; and (3) One or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. Impairment of communication is assigned numerical designations as follows: (0) Able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language; (1) Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas; (2) Inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time. Can generally communicate complex ideas; (3) Inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time. May rely on gestures or other alternative modes of communication. Able to communicate basic needs; and (Total) Complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both. Unable to communicate basic needs. Impairment of consciousness is assigned numerical designations as follows: Total - Persistently altered state of consciousness, such as vegetative state, minimally responsive state, coma. See 38 C.F.R. § 4.124a, DC 8045. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" with manifestations of a co-morbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. As for the history of the disability in issue, the Veteran's service treatment records show that in July 1994, he was hospitalized for about five days after he sustained a mild concussion and scalp laceration after he was hit by the side mirror of a bus while walking along a road. For the time period in issue, VA progress notes dated beginning in 2009 note complaints of jerking, with problem lists that included "myoclonic jerking" and notations that the Veteran has chronic myoclonic jerking, and that he was unable to do ADLs (activities of daily living). The findings tend to show the following: The Veteran was alert and oriented to time, place, person and/or situation. Speech was intact and fluent. Comprehension and repetition, and sensation in the extremities, were intact. Deep tendon reflexes were +2 and symmetrical. FTN (finger-to-nose) and HTS (heel-to-shin) tests were normal bilaterally. Gait was normal, or antalgic due to right knee pain. Muscle strength was 5/5 in the upper and lower extremities. There was no muscle wasting, memory loss or dizziness. There was mild weakness in the extremities. Electroencephalograms (EEGs) were normal in 2016 (with muscle artifacts) and 2017. In 2019, he stated his name and social security number for identification. He was noted to be independent in a number of activities of daily living, to include managing his financial matters. He had no barriers to learning and no reading limitations. A VA examination report, dated in August 2009, shows that on examination, the cranial nerves II through XII are intact. Motor strength is 5/5 in the upper and lower extremities. Deep tendon reflexes are +1 in the upper extremities, at the knees and ankles. Plantar reflexes were equivocal. Sensation on pinprick and light touch examination are diminished just proximal to the wrists and from mid-leg down. Sensation to vibration was impaired at the metacarpal (MTP) joints and medial malleoli. Finger-to-nose test (FTN) and heel-shin test (HST) were normal. An MRI (magnetic resonance imaging study) was noted not to indicate any central nervous system pathology. The Veteran was alert and oriented times three. He ambulated with a cane. A VA examination report, dated in January 2010, shows that on examination, the Veteran was alert and oriented times three. There were no cerebellar signs. The findings as to motor strength, deep tendon reflexes, the cranial nerves, and sensation were comparable to those in the August 2009 VA examination report. The impression was functional jerk movement. A VA mental disorders DBQ, dated in February 2015, shows that the Veteran was alert and oriented to person, place, date, and situation. There was no tangentiality, circumstantiality, flight of ideas, or loosening of associations to his speech. His thought processes were linear and logical. When asked to subtract 7 from 100, he correctly answered 93, however, he could not do a serial 7 test. He had 3/3 immediate object recall and 2/3 delayed object recall. His insight and judgment were intact. There was no overt evidence of any cognitive deficit. A VA DBQ, dated in April 2015, shows that on examination, the Veteran was noted not to have any muscle weakness in the upper or lower extremities. Speech was normal. Strength was 5/5 in the upper and lower extremities. Deep tendon reflexes were 1+ in the upper and lower extremities. There was no cognitive impairment. The Veteran used a cane due to right knee pain. There was no impact on his ability to work due to a disorder of the central nervous system. A VA DBQ, dated in May 2016, shows that on examination, the Veteran's judgment, motor activity, and consciousness, were normal. There were no subjective symptoms or neurobehavioral effects. Social interaction was routinely appropriate. He was occasionally disoriented to one of the four aspects (person, time, place, and situation). A September 2017 VA DBQ shows that on examination, the examiner indicated that there was no muscle weakness in the upper or lower extremities. Speech was normal. Strength was 4/5 in the upper and lower extremities. Deep tendon reflexes were normal in the upper and lower extremities. There was no muscle atrophy. The Veteran regularly used a cane. A VA DBQ, dated in January 2018, shows that the diagnosis was myoclonic jerking. The Veteran reported that he was unable to do a lot of ADLs due to his symptoms. On examination, speech and gait were abnormal. There was severe weakness in the upper and lower extremities. The Veteran had an antalgic gait leaning towards his left side. He walks with a cane and has to have rails and guards to help with balance. Strength was between 3/5 and 4/5 in the upper and lower extremities. Deep tendon reflexes were 1+ in the upper and lower extremities. The Veteran's thought processes are intact. He does have some difficulty remembering questions that were just asked of him. He repeats some phases several times throughout the conversation and he had noticeable frustration with not being able to finish sentences completely. He uses a cane constantly and a walker occasionally due to symptoms related to jerking and his right knee. A VA examination for housebound status or permanent need for aid and attendance, dated in September 2019, notes that the Veteran's symptoms include poor short-term memory. Bilateral hand grip was weak. Fine motor skills were poor, and balance and propulsion were moderately limited, due to age-related joint pain, stiffness, involuntary jerking, and pain. The Board finds the criteria for an initial evaluation in excess of 10 percent have not been met. The evidence shows that the Veteran has considerable impairment, to include severe impairment of motor activity, due to his myoclonic jerks, and depression. However, these disorders have been evaluated separately. 38 C.F.R. § 4.14. Upon consideration of the relevant facets discussed for evaluation of cognitive impairment and other residuals of TBI not otherwise classified, none warrant assignment of more than "1" level of impairment. The evidence indicates that the Veteran has normal social interaction, orientation, communication, and consciousness. There is no evidence of three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships. There is also no basis to find that the Veteran has physical (including neurological) dysfunction warranting an increased evaluation. Short-term memory was recently noted to be "poor," but there is no objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. In summary, the evidence is insufficient to show that the required symptoms for an initial evaluation in excess of 10 percent are present in both degree and frequency. Therefore, an initial evaluation in excess of 10 percent under 38 C.F.R. § 4.124a, DC 8045 is not warranted. 2. SMC based on the need for Aid and Attendance. In August 2016, the RO denied a claim for special monthly compensation based on housebound criteria or based on the need for Aid and Attendance. The Veteran appealed, and in January 2018, the RO granted the claim to the extent that it granted special monthly compensation based on housebound criteria under 38 U.S.C. § 1114 (s). Since this did not constitute a full grant of the benefit sought, the SMC issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). "Special monthly compensation" is payable to a person who is permanently bedridden or so helpless as a result of service-connected disability that he is in need of the regular aid and attendance of another person. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). The following will be accorded consideration in determining the need for regular aid and attendance: Inability of a claimant to dress or undress him or herself, or to keep him or herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of a claimant to feed him or herself through loss of coordination of the upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a claimant from the hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352 (a). It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352 (a) be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there is a constant need. See Turco v. Brown, 9 Vet. App. 222 (1996). The critical question to be determined in this case is whether the Veteran's service-connected disabilities have resulted in the need for regular aid and attendance of another person because of resultant helplessness due to mental and/or physical impairment. Service connection is currently in effect for: myoclonic jerking, evaluated as 60 percent disabling, headaches, post-traumatic with neck pain, evaluated as 30 percent disabling, unspecified depressive disorder, evaluated as 30 percent disabling, left temporal area scar, evaluated as 10 percent disabling, TBI, evaluated as 10 percent disabling, and bilateral hearing loss, evaluated as noncompensable. The Veteran's combined rating is 80 percent. The Veteran's VA progress notes have been discussed, supra. In addition, VA progress notes show that in March 2018, the Veteran was indicated to travel independently on public transportation or to drive his own car. VA progress notes dated beginning in 2018 include findings that he is continent of bowel and bladder, that he drives around town, that he is independent in bathing, dressing, toileting, transfers, and feeding, and that he is partially dependent in management of money and medication. He does not need supervision, direction or personal assistance with bathing. There was also a finding of a need for a partial assist in daily hygiene. He is able to walk around his house and complete his ADL's (March 2018 report). Scores for the instrumental activities of daily living (IADL) scale show that he scored 8 out of 8 points in March 2018 and 5 out of 8 points in April 2019. The 2019 report showed that no points were awarded for shopping, food preparation, or responsibility for own medications, but points awarded for such things as performing light daily tasks such as dishwashing, bed-making, and being able to launder small items, rinse stockings, etc., and being able to arrange his own travel via taxi "but does not otherwise use public transportation," and managing his financial matters. A VA examination report, dated in June 2016, shows the following: The Veteran is able to feed himself and prepare his own meals. He does not need assistance in bathing and tending to other hygiene needs. He does not require nursing home care. He requires medication management, which is done by his son. There were no restrictions in his lower extremities. There was some restriction in his spine, trunk, and neck, during myoclonic jerking episodes. He has generalized weakness in his extremities. He cannot drive a vehicle. He mostly only leaves the home for doctor's visits. Grip is weak. He can ambulate one block with an aid. The diagnosis was TBI with involuntary extremity movements. A VA examination report, dated in September 2019, shows the following: The Veteran has bilateral hearing loss, myoclonic jerking, chronic neck pain, chronic headache and syncope episodes, unsteady gait, and frequent falls. He has ADL restrictions due to his involuntary jerking, age, generalized weakness, fatigue, unsteady gait, chronic pain to his right first finger, age-related muscle and joint pain, severe hearing loss, poor short-term memory. He has trouble ambulating from a sitting position. His gait is unsteady, initially, then antalgic. He ambulates with a walker. His involuntary jerking aggravates his ambulation, along with his right knee pain with weight bearing. He has poor balance when ambulating. He is not confined to bed. He requires moderate assistance with feeding. He requires significant assistance with dressing, undressing, grooming, keeping himself clean and presentable, and toileting. He is incontinent of bowel and bladder. He needs assistance and managing medications due to his short-term memory an involuntary hand jerking. He was age-appropriately dressed, clean, and well kept. He has restrictions in feeding himself, dressing, fine movements, shaving, attending to the needs of nature, in the ranges of motion in his upper and lower extremities, and due to atrophy. He was noted to have a history of falls. He only leaves his home for medical appointments. He does not go outside the home for social gatherings or grocery shopping due to incontinence of bowel and bladder, risk of falling, painful joints, and shortness of breath on exertion. In July 2020, an advisory opinion was obtained from the Executive Director, Compensation Service. The opinion states: A single disability evaluated as 100-percent disabling under a schedular evaluation is generally a prerequisite for entitlement to A&A (aid and attendance) benefits. Thus, the claim has been referred for an opinion. It is noted the Veteran is service connected for myoclonic jerking, headaches, TBI, depressive disorder, scar, and hearing loss. The Veteran is 95 years of age and has multiple nonservice-connected disabilities. Thus, leading to the question of how much impairment is caused by the service-connected disabilities alone. A VA examination, dated in September 2019, clearly notes, "the reason for his ADL (activities of daily living) restriction is due to his involuntary jerking, age, generalized weakness, fatigue, unsteady gait, chronic pain to his right first finger, age-related muscle and joint pain, severe hearing loss, poor short-term memory." We have also reviewed the other evidence of record. The conclusion after reviewing the evidence of record is that the Veteran's service-connected disabilities alone do not render the Veteran incapable of performing his activities of daily living. Thus, a finding of Aid and Attendance is not supported, and such must be denied. (minor changes made for clarity). The Board finds that the criteria for special monthly compensation based on the need for aid and attendance have been met. Although the C&P Executive Director's Advisory Opinion is found to be probative, overall, the Board has afforded this Advisory Opinion no more than moderate probative weight, as it does not discuss the medical evidence in detail. The Board has afforded the medical and other evidence of record relatively more probative value than the Advisory Opinion. This evidence shows that the Veteran has significant impairment in multiple areas that cannot be ruled out as not related to his service-connected disabilities, to include the ability to dress and undress himself, to keep himself ordinarily clean and presentable, the ability to feed himself, and the ability to attend to the wants of nature. There is also evidence of a history of falls inside the home, raising a reasonable doubt as to whether he requires care or assistance on a regular basis to protect him from the hazards or dangers incident to his daily environment. Accordingly, affording the Veteran the benefit of all doubt, the Board finds that the evidence is at least in equipoise, and that the criteria for special monthly compensation based on the need for aid and attendance are shown to have been met. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.S.E., 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.