DEMENTIA

Summary

The Veteran, a Veteran who served from September 1963 to September 1967, appeals the denial of service connection for Alzheimer's dementia as secondary to bilateral hearing loss and the denial of special monthly compensation (SMC) for aid and attendance. The Board found that the Veteran's Alzheimer's dementia is aggravated by his service-connected bilateral hearing loss, granting service connection on a secondary basis. This decision was supported by multiple VA medical opinions and private medical literature linking hearing loss to an increased risk of cognitive decline and dementia. Although one VA opinion was negative, the Board found the positive opinions and submitted research more persuasive, noting that the Veteran's TERA exposure was also a contributing factor. The Board also granted entitlement to SMC for aid and attendance, finding that the Veteran's dementia necessitates regular personal assistance with daily activities such as bathing, dressing, toileting, and medication management, as corroborated by VA examinations and his wife's caregiving efforts. The Board concluded that the Veteran's condition warrants the grant of SMC.

Rationale

Aggravated by service-connected bilateral hearing loss; Supported by multiple VA and private medical opinions; Medical literature shows link between hearing loss and dementia risk

Full Decision Text

Citation Nr: A26037052
Decision Date: 04/21/26	Archive Date: 04/21/26

DOCKET NO. 260401-642855
DATE: April 21, 2026

ORDER

Entitlement to service connection for Alzheimer's dementia as secondary to bilateral hearing loss is granted.

Entitlement to special monthly compensation based on the need for aid and attendance is granted.

FINDINGS OF FACT

1. The Veteran's Alzheimer's dementia is aggravated by his service-connected bilateral hearing loss.

2. The Veteran's now-service-connected disability of dementia caused him to need regular aid and attendance.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for Alzheimer's dementia as secondary to service-connected hearing loss have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for SMC based on the need for aid and attendance due to service-connected disabilities have been met. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served honorably on active duty from September 1963 to September 1967.

In the March 2026 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket.

Therefore, the Board may only consider the evidence of record at the time of the March 2026 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 

The period to change AMA dockets per 38 C.F.R. § 20.202(c)(2) has not elapsed.  However, the record reflects that the Veteran expressly waived the right to change dockets, permitting the Board to continue adjudicating these claims, so there is no prejudice to the Veteran in proceeding to adjudicate the issues on appeal on the merits.  Williams v. McDonough, 37 Vet. App. 305 (2024).

This appeal has been advanced on the docket due to the Veteran's age pursuant to 38 U.S.C. § 7107(b); 38 C.F.R. §§ 20.800(c), 20.902(c). 

 Applicable Law

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 established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Service connection on a secondary basis requires (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability either (a) caused, or (b) aggravated, the nonservice-connected disability. 38 C.F.R. § 3.310; Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

Certain chronic disabilities, such as arthritis, are presumed to have been incurred in service, even though there is no evidence of such disease during the period of service, if they manifest to a compensable degree
; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability either (a) caused, or (b) aggravated, the nonservice-connected disability. 38 C.F.R. § 3.310; Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

Certain chronic disabilities, such as arthritis, are presumed to have been incurred in service, even though there is no evidence of such disease during the period of service, if they manifest to a compensable degree within one year of discharge. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.  Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

For purposes of establishing service connection for a disability resulting from exposure to an herbicide agent, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 U.S.C. § 1116 (f).  If a Veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected even though there is no record of such disease during service. 38 C.F.R. § 3.309 (e). 

The diseases listed at 38 C.F.R. § 3.309 (e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and early-onset peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307 (a)(6)(ii).

It is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104 (a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve all reasonable doubt in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. In other words, if the positive and negative evidence is in approximate balance, the claimant receives the benefit of the doubt. See Lynch v. McDonough, 21 F. 4th 776 (Fed. Cir. 2021).

1. Entitlement to service connection for Alzheimer's dementia as secondary to bilateral hearing loss is granted.

In May 2024, the Veteran filed a fully developed claim seeking entitlement to service connection for Alzheimer's dementia as secondary to bilateral hearing loss among other claims.  A September 2024 rating decision denied the Veteran's claim but made the favorable findings that (1) the Veteran participated in a toxic exposure risk activity (TERA), (2) the Veteran has a current diagnosis of dementia, and (3) the Veteran's primary disability of bilateral hearing loss is service connected. The Board is bound by these favorable findings. 38 C.F.R. § 3.104 (c).

In December 2025, the Veteran filed a supplemental claim and submitted research as well as a positive nexus letter regarding the connection between bilateral hearing loss and Alzheimer's dementia.  A March 2026 rating decision again denied the Veteran's claim for service connection for Alzheimer's as secondary to bilateral hearing loss.

Turning to the evidence of record, VA medical opinions were obtained in August 2024, February 2026, and in March 2026. 

In the first August 2024 VA examination, the examiner noted a negative rationale for secondary service connection causation but wrote, "the Vet's primary diagnosis is Dementia and that condition, and its effects are exacerbated by the loss of hearing."  No aggravation opinion was provided.  In the second August
5, the Veteran filed a supplemental claim and submitted research as well as a positive nexus letter regarding the connection between bilateral hearing loss and Alzheimer's dementia.  A March 2026 rating decision again denied the Veteran's claim for service connection for Alzheimer's as secondary to bilateral hearing loss.

Turning to the evidence of record, VA medical opinions were obtained in August 2024, February 2026, and in March 2026. 

In the first August 2024 VA examination, the examiner noted a negative rationale for secondary service connection causation but wrote, "the Vet's primary diagnosis is Dementia and that condition, and its effects are exacerbated by the loss of hearing."  No aggravation opinion was provided.  In the second August 2024 opinion, the examiner provided a positive TERA opinion, stating that the "Vet was exposed to herbicides while in service. These herbicides have had a negative impact on his neurology and have caused a symptom profile that most closely reflects a diagnosis of Dementia." 

In December 2025, the Veteran submitted a positive nexus opinion from his primary care doctor who treats his dementia.  Dr. V stated that "studies show that hearing loss is an independent risk factor for dementia and Alzheimer's disease.  The patient's hearing loss plays a part and contributed to his Alzheimer's disease."  The Veteran also submitted research articles in May 2024 and in December 2025 showing a link between hearing loss and a higher risk of developing Alzheimer's.  

In a February 2026 VA opinion, the examiner gave a positive nexus opinion regarding secondary service connection, stating "it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's Alzheimer's disease is aggravated by his bilateral hearing loss, given the potential mechanisms through which hearing impairment can contribute to or worsen cognitive decline. Multiple studies have shown an association between hearing loss and increased risk of cognitive decline and dementia. Hearing loss can lead to reduced auditory input, which could potentially contribute to diminished cognitive reserve, increased social isolation, and thereby exacerbate cognitive decline. Hearing impairment is recognized as an important modifiable risk factor for dementia." 

VA sought an addendum opinion.  In the March 2026 addendum opinion, the VA examiner changed her positive nexus opinion to a negative opinion, stating that "the Veteran's hearing loss, while having some potential impact on overall cognitive load, does not meet the severity required to be classified as a significant

causal factor for Alzheimer's dementia."  

A second March 2026 VA opinion from a different examiner opined that the Veteran's Alzheimer's dementia was less likely than not aggravated beyond its natural progression by the Veteran's service-connected condition. Rationale is that Alzheimer's disease is a chronic, progressive, terminal disease. It is scientifically proven to be aggravated by the buildup of amyloid beta peptides and tau protein in the brain. Although patients can be at a greater risk for Alzheimer's disease if they have hearing loss, the use of hearing aids greatly decreases that risk."

In April 2026 correspondence, the Veteran's representative argued that VA overdeveloped the claim seeking negative evidence: "Inexplicably, after being in receipt of five different medical opinions, that positively link [the Veteran's] Alzheimer's to his service connected hearing loss or due to his in service TERA, the rating activity requested an exam rework on February 27th, 2026." See April 1, 2026, correspondence.

The Board agrees that this development was unnecessary as the medical evidence of record clearly shows a connection between the Veteran's service-connected bilateral hearing loss and his Alzheimer's.  A disability which is proximately due to or the result of a service-connected disease or injury, to include on the basis of aggravation, shall be service connected.  

In light of the August 2024, December 2025 and February 2026 medical opinions finding the Veteran's service-connected hearing loss exacerbated or contributed to his Alzheimer's dementia and the medical literature submitted by the Veteran showing an increased risk of Alzheimer's due to hearing loss, the Board finds that the Veteran's Alzheimer's dementia was aggravated by his service-connected hearing loss.  

The Board notes that although 38 C.F.R. § 3.310 (b) indicates that VA will not concede aggravation unless the baseline severity of the nonservice-connected disease or injury is established, the next sentence indicates that the rating activity will determine the baseline and current levels of severity and determine the extent of aggravation. Given that the Board is not bound by the AOJ's determination that aggravation is not present, and as the Board does not assign ratings in the first instance, the Board reads 38 C.F.R. § 3.310 (b) as permitting the Board to determine whether service connection on an aggravation basis is warranted, with the AOJ having the
 was aggravated by his service-connected hearing loss.  

The Board notes that although 38 C.F.R. § 3.310 (b) indicates that VA will not concede aggravation unless the baseline severity of the nonservice-connected disease or injury is established, the next sentence indicates that the rating activity will determine the baseline and current levels of severity and determine the extent of aggravation. Given that the Board is not bound by the AOJ's determination that aggravation is not present, and as the Board does not assign ratings in the first instance, the Board reads 38 C.F.R. § 3.310 (b) as permitting the Board to determine whether service connection on an aggravation basis is warranted, with the AOJ having the responsibility for determining the degree of aggravation in assigning the rating. See Ward v. Wilkie, 31 Vet. App. 233 (2019) (regarding § 3.310, "The Court concludes that the 'permanent worsening' standard has no application in cases involving an incremental increase in disability of a non-service-connected condition proximately due to or the result of a service-connected disease or injury."). 

Accordingly, entitlement to service connection for Alzheimer's dementia associated with bilateral hearing loss is granted.

The Board notes that the Veteran had toxic exposure to Agent Orange and asbestos.  Alzheimer's is not one of the presumptive diseases listed at 38 C.F.R. § 3.309 (e).  Although the second August 2024 VA TERA opinion found a positive nexus between the Veteran's Alzheimer's condition and his TERA exposure, the bulk of the evidence shows that the Veteran is entitled to service connection based on secondary service connection aggravation.

2. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is granted.

Special monthly compensation (SMC) is a form of special ratings for service-connected disabilities. 38 C.F.R. § 3.350. SMC is payable under 38 U.S.C. § 1114(l) when a Veteran's service-connected disability or disabilities render him permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). 

Determinations as to the need for regular aid and attendance are factual and must be based upon the actual requirements for personal assistance from others. In making such determinations, consideration is given to such conditions as: the inability of the claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; the frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the disability cannot be done without assistance. The inability of the claimant to feed himself through the loss of coordination of upper extremities or extreme weakness; inability to attend to the wants of nature; or incapacity, either physical or mental, which requires care or assistance on a regular basis to protect a claimant from hazards or dangers incident to one's daily environment. It is not required that all the disabling conditions enumerated be present before a favorable rating is made.

The personal functions that the claimant is unable to perform should be considered in connection with his entire condition. It is only necessary that the claimant be so helpless as to need regular aid and attendance, not that there is a constant need.

"Bedridden" constitutes a condition which, through its essential character, requires that an individual remains in bed. 38 C.F.R. § 3.352 (a); Turco v. Brown, 9 Vet. App. 222, 224 (1996) (eligibility for SMC by reason of the regular need for aid and attendance requires that at least one of the factors outlined in VA regulation is met). The evidence must show that the Veteran is so helpless as to need regular aid and attendance; constant need for aid and attendance is not required. 38 C.F.R. § 3.352 (a). The fact that a claimant has voluntarily taken to bed or that a physician has prescribed bed rest for a lesser or greater portion of the day will not suffice. Id. The need must be based on the actual requirement of personal assistance from others.

The March 2026 rating decision under review denied SMC-l but made the favorable finding that the Veteran requires aid and attendance. In March 2026, the Veteran submitted an Examination for Housebound Status or Permanent Need for Aid and Attendance signed by his VA physician. This shows that the Veteran needs help with bathing/showering, dressing, tending to hygiene needs, toileting and medication management.  The Veteran is noted to be incontinent and have balance issues resulting in falls. The Veteran is unable to leave his home unaccompanied and needs supervision.

Medical records note that the Veteran's confusion and visual hallucinations have become more
 the day will not suffice. Id. The need must be based on the actual requirement of personal assistance from others.

The March 2026 rating decision under review denied SMC-l but made the favorable finding that the Veteran requires aid and attendance. In March 2026, the Veteran submitted an Examination for Housebound Status or Permanent Need for Aid and Attendance signed by his VA physician. This shows that the Veteran needs help with bathing/showering, dressing, tending to hygiene needs, toileting and medication management.  The Veteran is noted to be incontinent and have balance issues resulting in falls. The Veteran is unable to leave his home unaccompanied and needs supervision.

Medical records note that the Veteran's confusion and visual hallucinations have become more prominent, with increased behavioral issues such as leaving the house in the middle of the night or getting into stranger's cars. The record reflects that the Veteran's wife has had to take care of all the Veteran's needs. See CAPRI records submitted February 2026.

Upon review of the record, the Board finds the persuasive weight of the evidence is in favor of finding that the Veteran needs permanent aid and attendance due to his dementia (Alzheimer's type). 

Accordingly, the Board special monthly compensation based on the need for regular aid and attendance is warranted. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352.

 

 

MARJORIE A. AUER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Ann Newton

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.