Citation Nr: 21009355 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 10-31 777 DATE: February 22, 2021 ORDER Entitlement to service connection for a dementia disorder, to include Alzheimer’s disease is denied. FINDING OF FACT Prior to his death, the Veteran’s dementia/Alzheimer’s was not present in service and was not otherwise etiologically related to service or service-connected disability. CONCLUSION OF LAW The criteria for service connection for dementia disorder, to include Alzheimer’s disease, are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1951 to February 1953. He died in April 2009 and the appellant is his surviving spouse. In October 2010, the Agency of Original Jurisdiction (AOJ) determined that his surviving spouse qualified as a substitute party. In December 2010, she testified at a hearing before the Board and a transcript of the hearing is of record. The case has since been remanded multiple times for additional development, most recently in March 2020. As the record shows the Veteran had diagnoses for dementia and Alzheimer’s disease, the claim was expanded and recharacterized as indicated above. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Service Connection Prior to his death, the Veteran sought service connection for dementia/Alzheimer’s disease. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as “chronic” by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, any reasonable doubt is resolved in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. At her December 2010 Board hearing, the appellant essentially testified that the Veteran’s dementia/Alzheimer’s was caused by his service-connected Paget’s disease. See December 2010 Board Hearing Transcript. Additionally, VA medical records suggested a possible correlation between the Veteran’s dementia and his service-connected Parkinson’s disease. See June 2005 VA outpatient treatment records. Although prior to his death the Veteran appeared to have limited his argument to principles of secondary service connection, direct service connection was also considered by the AOJ during the course of the appeal. In May 2014, July 2016, and September 2016, the AOJ obtained VA medical opinions. Each VA examiner rendered a negative nexus opinion as to whether the Veteran’s dementia/Alzheimer’s was etiologically related to service or his service-connected cold exposure. They explained that records were silent for signs of Alzheimer’s disease during service or for over a year after service. They also noted a lack of peer-reviewed literature supporting that Alzheimer’s disease was caused by cold exposure or injury. Likewise, in October 2020, after reviewing the Veteran’s history, a VA examiner concluded the Veteran’s Alzheimer’s dementia was not caused or aggravated by his service-connected Parkinson’s and Paget’s diseases. Citing to medical journals and online medical references, the examiner explained that the neuropathology of Parkinson’s and movement disorders is associated with dysfunction involving the basal ganglia and or the cerebellum. In addition, Paget’s disease is an autoimmune inflammatory disease associated with frontotemporal dementia which initially is characterized with remembering words and names, difficulty with speaking, dyscalculia, personality changes, and inappropriate behavior. She noted that when the Veteran’s idiopathic Parkinson’s disease was diagnosed in 2006, he was prescribed medication with some noted improvement as well as intact comprehension, memory, calculation, naming, and reading. The examiner also noted that risk factors for developing dementia include age, cardiovascular problems, genetics, brain injuries, diabetes, Parkinson’s disease, and depression. However, not all individuals with Parkinson’s develop dementia and the risk of dementia increases with age. The examiner determined that the Veteran’s Alzheimer’s dementia was multifactorial, with age being the main and primary factor. So while it was not possible to assess the impact service-connected and non-service-connected risk factors might have on the Veteran’s functioning without resorting to speculation, the examiner reiterated that there was no cause and effect relationship between his dementia and his service-connected disabilities. Based on the foregoing, the Board finds there is no probative and competent medical evidence of record to indicate that any of the Veteran’ s service-connected disabilities played a role in the development of his dementia/Alzheimer’s. Collectively the VA opinions are both probative and persuasive as they are based an accurate medical history and supported by sufficiently clear and well-reasoned medical rationales consistent with the verifiable facts regarding the appellant’s contentions. The VA examiners considered the onset and course of the pertinent symptoms, the results of previous clinical evaluations and reviewed medical references related to the likelihood or not that the Veteran’s dementia developed as a result of his service-connected disabilities. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). There are also no favorable competent opinions of record. The Board acknowledges that the March 2020 clinician found other variables that could impact the Veteran’s dementia and that she could not assess/rule them out without resorting to speculation. However, in the end she gave a clear definitive opinion, therefore the opinion is not considered inadequate so as to require an addendum. See Jones v. Shinseki, 23 Vet. App. 382 (2011). With regard to whether the evidence establishes a direct connection between the Veteran’s service and his dementia/Alzheimer’s, the Board notes that service treatment records fail to reveal any pertinent signs or symptoms prior to his separation from service in 1953 and the earliest post-service evidence (documentation) of pertinent symptoms or complaints is in 2008 more than 50 years after service. Moreover, any assertions by the appellant that her husband’s dementia/Alzheimer’s was related to service would tread into the realm of medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). In any event, the probative value of her belief is outweighed by that of the examiner, who clearly does have the education, training and experience to address etiology.   Because the Veteran’s dementia/Alzheimer’s was not present in service, and there is no competent medical evidence relating it to service or service-connected disability, the claim cannot be granted. 38 C.F.R. §§ 3.303, 3.310; Allen, supra; see also, Wallin, Reiber, supra. Accordingly, the preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). M. MAC Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Bryant, Jeana R 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.