DEMENTIA

Summary

The veteran, who served in the Army from January 1956 to December 1957 and the Marine Corps from August 1959 to September 1977, was awarded the Purple Heart, Combat Infantry Badge, and Air Medal. The veteran passed away in 2009, and his surviving spouse, the Appellant, has been substituted as the claimant. The veteran was previously granted service connection for diabetes and later for coronary artery disease (CAD). The Appellant contended that the veteran's dementia was secondary to his service-connected diabetes and CAD. The Board reviewed the evidence, including a January 2026 private medical opinion that found the veteran's Alzheimer's dementia to be at least as likely as not a direct result of his service-connected diabetes and CAD. This opinion provided a detailed pathophysiological rationale linking cardiometabolic disease to vascular cognitive impairment. The Board found the evidence evenly balanced, resolving doubt in the veteran's favor, and granted service connection for dementia secondary to diabetes and CAD, effective March 7, 2002. The Board also granted a Total Disability based on Individual Unemployability (TDIU) for CAD from March 7, 2002, and SMC(s)(1) from July 25, 2006. Several other SMC claims were remanded for further adjudication.

Rationale

Current disability established (dementia prior to death); Service-connected diabetes and CAD established; Private examiner provided positive opinion linking dementia to diabetes and CAD; Evidence evenly balanced, doubt resolved in veteran's favor

Full Decision Text

Citation Nr: 26004098
Decision Date: 04/02/26	Archive Date: 04/02/26

DOCKET NO. 14-38 301A
DATE: April 2, 2026

ORDER

Entitlement to service connection for microvascular disease, also claimed as dementia of the Alzheimer's type (dementia), secondary to service-connected diabetes mellitus type II (diabetes) and coronary artery disease (CAD) is granted.

Entitlement to a total disability rating due to individual unemployability (TDIU), solely due to service-connected CAD, from March 7, 2002, is granted, subject to controlling regulations governing the payment of monetary awards.

Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(s)(1) from July 25, 2006 is granted, subject to controlling regulations governing the payment of monetary awards.

REMANDED

Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (l) based on the need for aid and attendance is remanded.

Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (o) is remanded.

Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (r)(2) is remanded.

Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (s)(1), prior to July 25, 2006, is remanded.

FINDINGS OF FACT

1. The Veteran's dementia was at least as likely as not caused by his service-connected diabetes and CAD. 

2. From March 7, 2002, the Veteran's CAD, alone, precluded all substantially gainful employment for which his education and occupational experience otherwise qualified him.

3. The Veteran is now retroactively in receipt of a TDIU due to service-connected CAD alone and had additional disabilities ratable at 60 percent or more from July 25, 2006.

CONCLUSIONS OF LAW

1. The criteria for service connection for dementia, secondary to service-connected diabetes and CAD on a causation basis, have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. From March 7, 2002, the criteria for a TDIU, due solely to service-connected CAD, are met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16.

3. From July 25, 2006, the criteria for SMC pursuant to 38 U.S.C. § 1114(s)(1) are met.  38 U.S.C. § 1114(s)(1).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the Army from January 1956 to December 1957 and in the Marine Corps from August 1959 to September 1977.  The Veteran was the recipient of a Purple Heart, Combat Infantry Badge, and the Air Medal.  He passed away in 2009; the Appellant, his surviving spouse, has been substituted as the claimant.  

These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision of the agency of original jurisdiction (AOJ) of the Department of Veterans Affairs (VA).

By way of history, an August 2002 rating decision granted service connection for diabetes and denied service connection for CAD; a July 2004 rating decision granted an earlier effective date for diabetes to May 8, 2001.  In July 2006, the Veteran filed an informal claim for diabetes, peripheral neuropathy, back condition, peripheral vascular disease, and hypertension.  In September 2006, the Veteran, in pertinent part, applied for SMC based on the need for aid and attendance, pursuant to 38 U.S.C. § 1114 (l).  A July 2007 rating decision denied entitlement to SMC based on the need for aid and attendance, as well as service connection for hypertension, diffuse idiopathic skeletal hyperostosis (DISH), peripheral arterial vascular disease, and peripheral neuropathy.  In April 2008, the Veteran filed a notice of disagreement (NOD) with regard to the service connection denials from the July 2007 rating decision; the denial of entitlement to SMC based on the need for aid and attendance became final as it was not appealed
  In September 2006, the Veteran, in pertinent part, applied for SMC based on the need for aid and attendance, pursuant to 38 U.S.C. § 1114 (l).  A July 2007 rating decision denied entitlement to SMC based on the need for aid and attendance, as well as service connection for hypertension, diffuse idiopathic skeletal hyperostosis (DISH), peripheral arterial vascular disease, and peripheral neuropathy.  In April 2008, the Veteran filed a notice of disagreement (NOD) with regard to the service connection denials from the July 2007 rating decision; the denial of entitlement to SMC based on the need for aid and attendance became final as it was not appealed and new and material evidence weas not received within one year of its issuance.  38 U.S.C. § 7105(c) (2012); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.1103 (2016); Williams v. Peake, 521 F.3d 1348 (Fed. Cir. 2008).  The Veteran subsequently passed away in January 2009.

A January 2012 rating decision granted service connection for CAD and granted an initial 30 percent rating effective June 17, 2002; this rating decision was a special review in accordance with Nehmer v. United States Department of Veterans Affairs.  The Appellant filed a notice of disagreement (NOD) in November 2012, was issued a Statement of the Case (SOC) in September 2014, and the Appellant appealed to the Board in November 2014, via VA Form 9, wherein she included a lengthy statement attesting the Veteran was incapacitated in 2006 necessitating treatment and subsequent confinement at the Lingerfelter Center until his death in 2009.  In a September 2018 decision, the Board, in pertinent part, denied an earlier effective date and increased rating for the Veteran's service-connected CAD.   

The Appellant appealed the September 2018 Board decision to the Court of Appeals for Veterans Claims (Court), contending the Board failed to consider evidence that reasonably raised the issue of a TDIU and SMC based on the need for aid and attendance.  The Appellant further argued that the Board should have considered the four pending claims the Veteran appealed in the April 2008 NOD.  In a February 2020 memorandum decision, the Court remanded the issues of earlier effective date and disability rating for CAD because the Board failed to consider evidence of unemployability and the need for aid and attendance, which the record reasonably raised.  

In a September 4, 2020 decision, the Board granted an earlier effective date of March 7, 2002 for the award of service connection for CAD, and remanded the CAD increased rating claim, as well entitlement to a TDIU and SMC based on the need for aid and attendance.  A September 16, 2020 rating decision continued the 30 percent rating for CAD and denied TDIU, and a September 17, 2020, SOC denied both as well as entitlement to SMC based on the need for aid and attendance.  In a May 2021 decision, the Board denied an increased rating for CAD and remanded TDIU and SMC based on the need for aid and attendance.  The Appellant was issued a Supplemental SOC (SSOC) in February 2023.

In July 2023, the Appellant's then-representative submitted an appellate brief wherein they contended that the Veteran's dementia was secondary to his diabetes, CAD and hypertension.  In August 2023, the Board remanded entitlement to TDIU and SMC based on the need for aid and attendance.  After the Appellant was issued a March 2024 SSOC, the Board, in a May 2024 decision, granted a TDIU effective July 25, 2006, denied a TDIU prior to July 25, 2006, and denied SMC based on the need for aid and attendance.  Neither the August 2023 nor May 2024 Board decision adjudicated service connection for dementia.  

The Appellant appealed the May 2024 Board decision to the Court.  In an April 2025 Joint Motion for Partial Remand (JPMR), the parties agreed vacatur and remand are warranted because the May 2024 Board decision failed to consider the symptoms of the Veteran's service-connected CAD when it denied entitlement to a TDIU prior to July 25, 2006, when it failed to address whether any of the Veteran
 July 25, 2006, denied a TDIU prior to July 25, 2006, and denied SMC based on the need for aid and attendance.  Neither the August 2023 nor May 2024 Board decision adjudicated service connection for dementia.  

The Appellant appealed the May 2024 Board decision to the Court.  In an April 2025 Joint Motion for Partial Remand (JPMR), the parties agreed vacatur and remand are warranted because the May 2024 Board decision failed to consider the symptoms of the Veteran's service-connected CAD when it denied entitlement to a TDIU prior to July 25, 2006, when it failed to address whether any of the Veteran's service-connected disabilities alone would support an award of TDIU thereby leading to eligibility for SMC (s)(1), failed to address the Appellant's arguments in the July 2023 brief that the Veteran should be service connected for dementia, and failed to address evidence when it indicating the Veteran was in need of regular aid and attendance.  

After multiple 90-day extensions, the above issues have returned to the Board for adjudication.  

Service Connection for Dementia

The Appellant, via her then-representative, contended in a July 2023 Appellate Brief that the Veteran's dementia was secondary to his diabetes, CAD and hypertension.  On remand, the April 2025 JMPR instructed the Board to adjudicate entitlement to service connection for dementia.  

Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in active military service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a).  Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a relationship between the current disability and the in-service disease or injury.  Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018).  Consistent with this framework, service connection is warranted for a disease first 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).  Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310 (a).

The Veteran was prescribed galantamine in September 2001 for Alzheimer's dementia symptoms.  An April 2006 examiner noted the Veteran had symptoms consistent with a progressive dementia such as Alzheimer's disease.  In September 2006, the Veteran's VA primary care doctor stated that his Alzheimer's dementia was worsening by the day.  A December 2006 VA examiner noted the Veteran had probable dementia of the Alzheimer's type.  He was subsequently a resident at the Lingenfelter Center for Alzheimer's Disease.  Taken together, the evidence makes clear the Veteran had dementia prior to his death, and therefore the current disability element is established.  Additionally, the Veteran is service-connected for diabetes and CAD, thereby satisfying the service-connected disability element of secondary service connection.  The dispositive question, therefore, is whether there was a relationship between the Veteran's dementia and his diabetes and/or CAD.  

To that end, a January 2026 private examiner provided a positive medical opinion, noting the Veteran's Alzheimer's dementia is at least as likely as not a direct result of his service-connected diabetes and CAD.  The private examiner reviewed the Veteran's claims file and provided a 10 page summary of the Veteran's medical history, wherein he stated from a pathophysiologic standpoint, the Veteran's service-connected diabetes and CAD were causal and materially aggravating contributors to his demential syndrome by promoting chronic cerebral microvascular injury, endothelial dysfunction, neuroinflammation, and impaired cerebral perfusion, all of which are well-described mechanisms linking cardiometabolic disease with vascular cognitive impairment and mixed dementia phenotypes including Alzheimer's Disease.  

The private examiner also included a thorough review of the medical literature, commenting on the relationship between diabetes, CAD and dementia.  The private examiner additionally noted that hypertension is a recognized modifiable risk factor for later-life cognitive impairment and dementia, particularly when coexisting with diabetes and atherosclerotic disease, such as dementia.  As this private opinion followed an exhaustive review of the Veteran's medical records and medical literature, and included an extremely thorough rationale, it warrants significant probative value.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a
 disease with vascular cognitive impairment and mixed dementia phenotypes including Alzheimer's Disease.  

The private examiner also included a thorough review of the medical literature, commenting on the relationship between diabetes, CAD and dementia.  The private examiner additionally noted that hypertension is a recognized modifiable risk factor for later-life cognitive impairment and dementia, particularly when coexisting with diabetes and atherosclerotic disease, such as dementia.  As this private opinion followed an exhaustive review of the Veteran's medical records and medical literature, and included an extremely thorough rationale, it warrants significant probative value.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed).

The record contains one probative medical opinion weighing in favor of service connection, and no evidence weighing against.  The evidence is therefore at least evenly balanced as to whether the Veteran's dementia is secondary to his service-connected diabetes and CAD on a causation basis.  Regarding effective date, the Veteran's award of service connection for CAD was effective March 7, 2002, and his award of service connection for diabetes was effective May 8, 2001.  As the Veteran's dementia is due to both the Veteran's diabetes and CAD, the effective date of the award of service connection for dementia is March 7, 2002, the first date both CAD and diabetes were service-connected.  

As the reasonable doubt by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for dementia, secondary to service-connected diabetes and CAD on a causation basis, is warranted from March 7, 2002.  See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.

TDIU

The Veteran was in receipt of a TDIU from July 25, 2006 until his death.  The Appellant, through her representative and consistent with the April 2025 JMPR, argues that TDIU is warranted from March 7, 2002 to July 25, 2006, and that the Veteran's unemployability was due to a single service-connected disability for the entire period from May 7, 2002 until the Veteran's death.  

A TDIU is provided where the combined schedular evaluation for service-connected disabilities is less than total.  38 C.F.R. § 4.16 (a).  VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded from obtaining or maintaining any gainful employment by reason of his or her service-connected disabilities.  38 C.F.R. §§ 3.340, 3.341, 4.16; Witkowski v. Collins, 38 Vet. App. 459 (2025) (en banc).   A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation."  See 38 C.F.R. §§ 3.340 (a)(1), 4.15.

In Ray v. Wilkie, 31 Vet. App. 58, 73 (2019), the Court defined the term "unable to secure and follow a substantially gainful occupation" as having two components: one economic and one noneconomic.  The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person.  The non-economic component includes consideration of the following: the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue.

Moreover, for purposes of entitlement to TDIU, marginal employment shall not be considered substantially gainful employment.  Generally, marginal employment shall be deemed to exist when a Veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce as the poverty threshold for one person.  Marginal employment may be held to exist on a "facts found basis" even when earned annual income exceeds the poverty threshold, including but not limited to "employment in a protected environment such as a family business or sheltered workshop."  Recently, the Court has qualified the meaning of "employment in a protected environment" within the context of 38 C.F.R. § 4.16(a).  In Labruzza v. McDonough, 37 Vet. App. 111, 123-24 (202
 substantially gainful employment.  Generally, marginal employment shall be deemed to exist when a Veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce as the poverty threshold for one person.  Marginal employment may be held to exist on a "facts found basis" even when earned annual income exceeds the poverty threshold, including but not limited to "employment in a protected environment such as a family business or sheltered workshop."  Recently, the Court has qualified the meaning of "employment in a protected environment" within the context of 38 C.F.R. § 4.16(a).  In Labruzza v. McDonough, 37 Vet. App. 111, 123-24 (2024), the Court defined "employment in a protected environment" as "a lower-income position that, due to the veteran's service-connected disability or disabilities, is shielded in some respect from competition in the employment market").

The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability."  Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993).  The issue is not whether the Veteran can find employment generally, but whether the Veteran can perform the physical and mental acts required by employment.  Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities.  See 38 C.F.R. §§ 3.341, 4.16, 4.19.

Turning to the evidence, the Appellant submitted a formal TDIU, via VA Form 21-8940, in November 2025 wherein she noted the Veteran had a high school education and was unemployable due to his service-connected CAD and diabetes.  The record shows the Veteran worked as a security guard until August 1998.  He filed a long-term disability insurance claim, which was granted because he was "totally disabled from performing any occupation" and showed he last worked on August 7, 1998 as a security guard.  The Veteran was not employed at any point during the appeal period.  

The Board has already found that prior to July 25, 2006, the Veteran's CAD symptoms, including shortness of breath, caused impairment in physical tasks.  As the Appellant's representative argued, shortness of breath would have prevented the Veteran from returning to his job as a security guard or similar occupations requiring regular standing or walking.  From July 25, 2006, the Board has found the Veteran was precluded from even light manual work due to his service-connected CAD, which presented as shortness of breath upon exertion.  Moreover, the Veteran's high school education and lack of work experience in sedentary job environments would have made transitioning to a less physically demanding occupation, where his shortness of breath could be mediated, especially challenging.    

The above evidence reflects that the Veteran had a high school education with occupational history predominantly in physically demanding jobs.  Overall, he experienced symptoms associated with his service-connected CAD that resulted in functional impairments that would significantly interfere with his ability to perform any type of substantially gainful employment, physical or non-physical, consistent with his education and occupational experience.  

The evidence is therefore approximately balanced as to whether the Veteran's service-connected CAD alone precluded gainful employment for which his education and occupational experience might have otherwise qualified him for the entire appeal period, March 7, 2002 to his passing in January 2009.  Therefore, entitlement to a TDIU due solely to the Veteran's service-connected CAD disability from March 7, 2002, is warranted.  

SMC

Under 38 U.S.C. § 1114(s)(1), entitlement to compensation at the specified rate is warranted if the Veteran has a single service-connected disability rated as total and additional service-connected disability or disabilities independently ratable at 60 percent or more.  Pursuant to 38 C.F.R. § 3.350(i), the additional service-connected disability or disabilities ratable at 60 percent must be separate and distinct from the 100 percent service-connected disability or involve different anatomical segments of bodily systems.  VA's Adjudication Procedures Manual elaborates that the fact that the single disability, evaluated as totally disabling, and additional disability or disabilities, independently evaluated as 60-percent or more disabling, share a common etiology, does not preclude entitlement.

The Veteran is now in receipt of a TDIU based solely on service-connected CAD from March 7, 2002.  From July 25, 2006, the Veteran was also in receipt of 20 percent
  Pursuant to 38 C.F.R. § 3.350(i), the additional service-connected disability or disabilities ratable at 60 percent must be separate and distinct from the 100 percent service-connected disability or involve different anatomical segments of bodily systems.  VA's Adjudication Procedures Manual elaborates that the fact that the single disability, evaluated as totally disabling, and additional disability or disabilities, independently evaluated as 60-percent or more disabling, share a common etiology, does not preclude entitlement.

The Veteran is now in receipt of a TDIU based solely on service-connected CAD from March 7, 2002.  From July 25, 2006, the Veteran was also in receipt of 20 percent ratings for service-connected right peripheral arterial vascular disease, left peripheral arterial vascular disease, and diabetes, and 10 percent ratings for service-connected low back condition, right lower extremity peripheral neuropathy, and left lower extremity peripheral neuropathy.  Together, these six service-connected disabilities combine to a 60 percent rating.  

The Court has held "section 1114(s) does not limit 'a service-connected disability rated as total' to only a schedular rating of 100%, and the Secretary's current regulation permits a TDIU rating based on a single disability to satisfy the statutory requirement of a total rating."  Bradley v. Peake, 22 Vet. App. 280, 293 (2008).  As the Veteran has a single disability rated as total based on TDIU due to CAD, and additional separate and distinct disabilities ratable at 60 percent from July 25, 2006, entitlement to SMC(s)(1) is warranted from this date.  

REASONS FOR REMAND

SMC is an additional level of compensation to veterans (above the basic levels of compensation payable based on disability ratings of 0 to 100 percent) for various types of anatomical losses or levels of impairment due solely to service- connected disabilities.  See 38 U.S.C. § 1114(k-s).  

The April 2025 JMPR remanded the issue of SMC based on the need for aid and attendance, pursuant to 38 U.S.C. § 1114 (l), to the Board for adjudication.  Prior to the case returning to the Board, the Appellant's representative submitted February 2026 correspondence contending the Veteran met the criteria for SMC pursuant to 38 U.S.C. § 1114 (r)(2) and §1114 (o), which itself requires a finding that the Veteran met the criteria at the (l) rate on two separate and distinct bases.  The Appellant's representative specifically contends that the Veteran met the criteria at the (l) rate based on the effects of his CAD and diabetes, and then separately and distinctly due to the cognitive impairment caused by his now service-connected dementia.  While the Board could adjudicate entitlement to SMC based on the need for aid and attendance in the first instance here, the §1114 (o) and §1114 (r)(2) are now inextricably intertwined with the downstream issue of an initial rating for the newly service-connected dementia.  

As such, on remand, the AOJ should first assign an initial rating and effective date for service-connected dementia, and then adjudicate in the first instance the Veteran's retroactive entitlement to SMC pursuant to § 1114 (l), (o), and (r)(1).  The AOJ should determine if the Veteran met the criteria for any other ancillary benefits, to include SMCs pursuant to 38 U.S.C § 1114, and specifically whether the Veteran is entitled to SMC (s)(1) earlier than July 25, 2006 after the initial rating for service-connected dementia has been assigned.     

Accordingly, the above issues are remanded for the following action:

1. After assigning an initial disability rating and effective date for the now service-connected dementia, adjudicate whether the Veteran met the criteria for SMC based on the need for aid and attendance pursuant to 38 U.S.C. § 1114 (l).  Specifically, determine whether the Veteran met the criteria for SMC based on the need for aid and attendance on two separate and distinct bases: one due to the effects of his CAD and diabetes, and second due to the cognitive impairment caused by his dementia.  

2. Once this is determined, adjudicate whether the Veteran met the criteria for SMC pursuant to 38 U.S.C. § 1114 (o), and if so, SMC pursuant to 38 U.S.C. § 1114 (r)(1).

3. Determine whether the Veteran met the criteria for SMC pursuant to 38 U.S.C. § 1114 (s)(1) prior to July