Citation Nr: 21031507 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 12-30 938 DATE: May 24, 2021 REMANDED Service connection for hypertension. Service connection for dementia. Special monthly compensation (SMC) based on the need for aid and attendance. REASONS FOR REMAND The Veteran served on active duty from June 1967 to June 1969. The case is on appeal from a September 2010 rating decision. Most recently, the Board remanded the claims on appeal for additional development in September 2020. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902. 38 U.S.C. § 7107(a)(2). 1. Service connection for hypertension. 2. Service connection for dementia. Issues 1-2 are remanded for a new VA opinion. The Veteran is seeking service connection for hypertension due to presumed Agent Orange exposure or secondary to service-connected coronary artery disease (CAD) or posttraumatic stress disorder (PTSD). He is also seeking service connection for dementia due to service or secondary to hypertension, CAD, or PTSD. In a January 2019 brief, the Veteran's representative at the time reported that medical research has indicated a link between PTSD and elevated blood pressure. The representative explained that the Veteran's PTSD results in hypervigilance and stress. In a March 2019 correspondence, the Veteran's representative reported that studies indicate stressful combat experiences are an independent risk factor for hypertension and indicate that PTSD is linked to physical inactivity, alcohol abuse, and weight gain. The representative also reported that studies show PTSD is associated with an increased risk of dementia and a connection between CAD and dementia. The representative provided internet addresses for the referenced studies. Thereafter, in an April 2021 correspondence, the Veteran's representative reported that The Veterans and Agent Orange: Update 11 (2018), by the National Academies of Sciences, Engineering and Medicine (NAS), stated that there is now "sufficient" evidence of an association between hypertension and herbicide exposure. The representative also denied that the Veteran has a family history of hypertension. The Veteran's private treatment records show that he was diagnosed with dementia due to a brain aneurysm in April 2007. In a June 2008 statement, the Veteran indicated that his aneurysm was caused by herbicide exposure. In a March 2015 decision, the Board found some evidence indicating that the Veteran's dementia may be related to hypertension. Pursuant to the September 2020 Board remand, the Veteran was afforded examinations in regard to these claims in November 2020. The examiner found that the Veteran's hypertension is not due to herbicide exposure or caused or aggravated by PTSD. The Veteran's representative argued in April 2021 that remand was needed for new opinions. The Board agrees. The November 2020 VA examination does not adequately address all the complex medical questions raised by the claims. The representative requested that the Veteran's treating physician be asked to complete a Disability Benefits Questionnaire (DBQ) to comply with the Board's remand directives. The Veteran is certainly free to ask his treating physician to complete DBQs. However, the Board is unable to direct this action upon remand. The Board is also mindful of correspondence in April 2021 indicating that the Veteran was in hospice care and requesting that the Board render a decision based on the evidence currently of record. Unfortunately, the evidence currently of record is insufficient to resolve the claims in his favor. Hence, to avoid adjudicating the issues based on an incomplete record, the Board finds that remand for the opinions remains needed. 3. SMC based on the need for aid and attendance. The Veteran is seeking SMC based on the need for aid and attendance. A June 2015 VA examiner indicated that the Veteran requires someone to be with him constantly due to dementia. Accordingly, this claim is also remanded because it is intertwined with the service connection claims on appeal. These claims are REMANDED for the following actions: 1. Forward the claims file to an appropriate VA examiner to obtain an opinion in regard to the nature and etiology of the hypertension. The need for an in-person examination should be determined by the assigned examiner. Thereafter, the examiner is asked to address: (a.) Whether it is at least as likely as not that hypertension had its onset during service, within one year of service, or is otherwise related to an in-service event, disease, or injury, to include exposure to herbicides (Agent Orange) or serving in combat. In answering this question, the examiner is asked to disregard whether the disorder is one for which a "presumption" is established and, instead, to answer whether the medical condition is a result of Agent Orange exposure even though it is not on the list of "presumptive" diseases. The examiner should particularly consider the November 2018 National Institute of Science (NAS) study finding "sufficient" evidence of a positive association between hypertension and exposure to tactical herbicides. The examiner should also consider the medical studies submitted by the Veteran's representative in March 2019. (b.) Whether the current condition is at least as likely as not (1) proximately due to, or (2) aggravated beyond its natural progression by a different medical condition, especially CAD or PTSD. If so, the examiner is asked to identify the primary medical condition. The examiner should consider the medical studies submitted by the Veteran's representative in March 2019. 2. Forward the claims file to an appropriate VA examiner to obtain an opinion in regard to the nature and etiology of the dementia. The need for an in-person examination should be determined by the assigned examiner. The examiner is asked to address: (a.) Whether it is at least as likely as not that the dementia is related to an in-service event, disease, or injury, to include exposure to herbicides (Agent Orange). The examiner is asked to disregard whether the disorder is one for which a "presumption" is established and, instead, to answer whether the Veteran's dementia is a result of herbicide exposure even though it is not on the list of "presumptive" diseases. (Continued on the next page) (b.) Whether the current condition is at least as likely as not (1) proximately due to, or (2) aggravated beyond its natural progression by a different medical condition, especially CAD or PTSD. If so, the examiner is asked to identify the primary medical condition. The examiner should consider the medical studies submitted by the Veteran's representative in March 2019. Corey Bosely Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Jimerfield 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.