Citation Nr: 21013045 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 19-22 228 DATE: March 8, 2021 REMANDED Entitlement to an increased rating for depressive disorder, currently rated 50 percent, effective January 13, 2015, is remanded. Entitlement to special monthly compensation (SMC) based on the need for the aid and attendance of another person is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1962 to September 1966. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from December 2017 and October 2018 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded in July 2020 for further development. 1. Entitlement to an increased rating for depressive disorder, currently rated 50 percent, effective January 13, 2015, is remanded. 2. Entitlement to special monthly compensation (SMC) based on the need for the aid and attendance of another person is remanded. The Board notes that additional relevant medical evidence has been added to the record since the last adjudication of the issue by the Agency of Original Jurisdiction (AOJ) by a December 2020 supplemental statement of the case. The Veteran has not submitted a waiver of AOJ initial consideration of that evidence. As the case is being remanded, the AOJ will have the opportunity to review this evidence. Further examination is required in order to determine if the Veteran's cognitive disorder may be due to service-connected disabilities or otherwise resulted from the Veteran's active service. As a preliminary matter, the Board observes that a September 2017 rating decision established service connection for other specified trauma and stressor related disorder, claimed as a mental disability to include anxiety and depression. In an October 2018 rating decision, the service-connected disability was updated to other specified depressive disorder, previously rated as other specified trauma and stressor related disorder. The Veteran was evaluated by VA for symptoms of dementia in 2013. Following PET scan of July 2013 and MRI brain scan of August 2013, a VA neurologist found that the diagnostic evidence indicated mixed cognitive disorder syndrome. with “cognitive vascular, Alzheimer, frontotemporal lobe, and even Lewy Body disease.” The neurologist noted that posttraumatic stress disorder is a recognized risk factor for a number of different dementia syndromes, most prominently Alzheimer’s and frontotemporal lobe disorder. At a September 2020 VA examination, the examiner found that the Veteran's major neurocognitive disorder due to multiple etiologies had worsened to such an extent that service-connected depression no longer had an effect on the Veteran. The examiner concluded that the cognitive disorder was less likely than not due to or the result of the service-connected depressive disorder. The examiner stated that the Veteran's cognitive disorder was more likely related to a “neurological disease,” noting that MRI studies showed ischemic changes in the brain with volume loss. However, the examiner did not address any other of the “multiple etiologies” noted in the diagnosis. The Board appreciates the opinion and reasoning offered by the September 2020 VA examiner. However, while the examiner offered an opinion regarding an ischemic vascular etiology for dementia, other etiologies, supported by diagnostic tests, were not addressed. Specifically, the examiner did not address whether depression was a risk factor for any of the multiple etiologies supported by the evidence. The Board finds that opinion incomplete. A remand is necessary to obtain further medical opinion. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 On remand, the Veteran should be provided VA examination by an appropriate specialist for an etiology opinion supported by adequate reasoning regarding whether a diagnosed cognitive disorder is caused or aggravated by service-connected depression. Furthermore, the Board cannot adjudicate the issue of entitlement to SMC as it is intertwined with the issue regarding service connection for a cognitive disorder. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. In a February 2021 brief, the Veteran’s representative raised the issue of entitlement to a TDIU. The RO has not yet considered the issue. Thus, the Board finds that, after giving the Veteran an opportunity to file a formal claim for a TDIU, and completing the other actions noted below, the RO should adjudicate that matter in the first instance, to avoid any prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). The matters are REMANDED for the following action: 1. Send the Veteran a VA Form 21-8940, to assist him to file a formal application for TDIU. 2. Send the Veteran and representative a letter requesting that the Veteran furnish any additional information or evidence pertinent to the claim for TDIU. The letter should specifically notify the Veteran of the criteria to establish entitlement to TDIU. 3. With any necessary authorization from the Veteran, make all reasonable efforts to obtain all relevant outstanding treatment records. All attempts to locate records must be documented in the claims file 4. Schedule the Veteran for a VA examination with a neurologist or other appropriate specialist physician to determine the etiology of a diagnosed neurocognitive disorder. The examiner must review the record and must note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should diagnose all neurocognitive disabilities found. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any neurocognitive disorder found on examination had its onset in or are otherwise related to service. The examiner should also opine as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed neurocognitive disability was caused by the service-connected disabilities. The examiner should further opine as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed neurocognitive disability has been aggravated (increased in severity beyond the natural progress of the disorder) by service-connected disabilities. The examiner should specifically address whether the service-connected psychiatric disability caused or aggravated the neurocognitive disorder. The examiner should also state whether or not it is possible to distinguish the symptoms of the service-connected mental disorder and the neurocognitive disorder. The examiner is requested to address the December 2014 VA diagnostic studies and neurology notes. If it is determined that there is another likely etiology for the neurocognitive disorder, that should be stated. The examiner should address whether symptoms of any diagnosed neurocognitive disorder can be differentiated from symptoms caused by depression and the extent to which the symptoms overlap. The examiner should indicate the degree of social and occupational impairment caused by service-connected disabilities, and should describe the symptoms, and their severity and frequency, that result in those levels of impairment. The examiner should state whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities. A complete rationale for all opinions expressed should be clearly provided. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals 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.