Citation Nr: 22019723 Decision Date: 04/02/22 Archive Date: 04/02/22 DOCKET NO. 15-21 015 DATE: April 2, 2022 ORDER Entitlement to service connection for Alzheimer's dementia, claimed as a mental disorder is granted. FINDING OF FACT The evidence is in approximate balance as to whether the Veteran's Alzheimer's dementia was proximately due to and/or aggravated by service-connected diabetes; thus, the Board resolves the benefit of the doubt in favor of the appellant. CONCLUSION OF LAW The criteria for entitlement to service connection for Alzheimer's dementia, claimed as a mental disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310, 3.1010. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1954 to January 1979. He died in January 2014. The appellant is the Veteran's surviving spouse, who has been recognized by VA as the eligible substitute claimant in the current appeal. See 38 C.F.R. § 3.1010. The appeal has a lengthy procedural history. Most recently, in November 2021 the Board remanded the appeal for additional development. Entitlement to service connection for Alzheimer's dementia, claimed as a mental disorder In February 2012, the Veteran submitted a claim of entitlement to service connection for a mental health disorder due to medication and treatment for urinary tract infections (UTI). In December 2012, VA denied service connection for a mental disorder. The Veteran disagreed with the decision and following the April 2015 statement of the case (SOC), the appellant perfected this appeal as a substitute claimant. In July 2018, the Board listed the issue as entitlement to service connection for an acquired psychiatric disorder claimed as dementia and has continued to do so. The Board also noted a prior diagnosis of depression and has made multiple requests for opinions concerning both dementia and depression. On review, private medical records note a history of depression during the appeal period but on review, it seems clear that the Veteran was seeking service connection for dementia which was the overwhelming disability. Further, examinations of record note no confirmed diagnosis of depression during the appeal period. Regardless, both depression and neurocognitive disorders due to Alzheimer's dementia are evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.71a, Diagnostic Codes 9312, 9434. Accordingly, and to better reflect the evidence and contentions of record, the issue is rephrased as entitlement to service connection for Alzheimer's dementia, claimed as a mental disorder. The claimant is not prejudiced by this action particularly given the disposition herein. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted on a secondary basis for a disability that is proximately due to a service-connected condition. 38 C.F.R. § 3.310(a). Service connection is also possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In October 2006, VA amended 38 C.F.R. § 3.310 to incorporate the decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service-connected disability. 38 C.F.R. § 3.310(b). Service treatment records show a couple reports of nervousness and depression or worry but are negative for any psychiatric treatment during service. A chronic psychiatric disorder was not noted or diagnosed during service, at separation, or for many years thereafter. The Veteran's Alzheimer's dementia was diagnosed in 2011. As to whether the Alzheimer's dementia is otherwise related to active service or events therein, the record contains multiple negative VA etiology opinions. See VA opinions dated in March 2019, April 2019, April 2021, May 2021, and August 2021. The opinions were based on review of the record and collectively supported by adequate rationale. The record does not contain probative evidence to the contrary. As noted, the Veteran initially claimed his condition was secondary to service-connected UTI. VA opinions indicate that while UTI can increase the incidence of acute cognitive changes during the actual UTI itself, these symptoms are only temporary and there is no evidence it caused or permanently aggravated his dementia. See e.g., VA opinions dated in March 2019, April 2021, May 2021, and November 2021. In February 2019, VA implemented a grant of service connection for diabetes mellitus. While the assigned effective date was February 23, 2012, evidence of record shows that the Veteran had this disorder since at least October 2001. In November 2021, a VA psychologist provided an opinion. While noting she was not a medical doctor, her responses were based on research which indicates there are multiple reasons why years of type 2 diabetes may lead to dementia. Alzheimer's disease has been called "type 3 diabetes" because of shared molecular and cellular features among diabetes and Alzheimer's. For example, insulin resistance in the brain can lead to the plaques and tangles of Alzheimer's disease. She noted that the Veteran's diabetes likely as not had a contribution to his dementia as evidenced by the research but to say with 50 percent certainty that the diabetes did or did not contribute to dementia would be speculation as there are a multitude of factors correlated to dementia. Thus, it was less likely as not that diabetes caused the dementia because he had other relevant contributing factors with the most important being age. Notwithstanding, based off the information that dementia can be multi-causal and research indicating diabetes' influence on dementia it can be said with 50 percent accuracy that the diabetes resulted in aggravation of the dementia. On review, the VA examiner stated that the Veteran's diabetes as likely as not contributed to dementia, that she could not state her opinion that it did or did not contribute with 50 percent certainty without speculation, and that it was less likely it caused the dementia. However, the medical research tends to support the claim and at the very least, the opinion indicates the service-connected diabetes aggravated his dementia. The Board observes that a 50 percent certainty is not required to grant the benefit. Rather, if the positive and negative evidence is in approximate balance, the claimant receives the benefit of the doubt. Lynch v. McDonough, 21 F.4th 766 (Fed. Cir. 2021). Based on the foregoing, the Board finds that the competent and credible evidence is approximately balanced as to whether the Veteran's Alzheimer's dementia was proximately due to and/or aggravated by service-connected diabetes. The benefit of the doubt doctrine applies and resolving reasonable doubt in the appellant's favor, secondary service connection is warranted. 38 U.S.C. § 5107(b); Lynch. The claim is granted. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Carsten, 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.