DEMENTIA

Summary

The Veteran, who served from June 1978 to June 1998, appeals the denial of service connection for a neurocognitive disorder claimed as secondary to his service-connected celiac disease with GERD. The Board found that the evidence was at least approximately evenly balanced regarding the secondary nexus. The Veteran has a diagnosis of neurocognitive disorder, with a September 2017 VA neuropsychology consult suggesting a link to celiac disease and vitamin deficiencies. A March 2025 private medical opinion from his primary care physician, Dr. Comenencia, concurred with this assessment, providing a reasoned analysis of the association between chronic celiac disease and neurological complications, including cognitive impairment. While some VA opinions were afforded little probative value due to lack of rationale or failure to consider all evidence, a July 2020 VA neurology consult also concurred with the September 2017 opinion. Given the approximate balance of positive and negative evidence, the Board resolved reasonable doubt in the Veteran's favor, granting service connection for the neurocognitive disorder as secondary to celiac disease with GERD.

Rationale

Evidence is at least approximately evenly balanced regarding secondary nexus.; Reasonable doubt resolved in Veteran's favor.; Concurrence between VA neurologist and private physician with September 2017 VA psychologist opinion.

Full Decision Text

Citation Nr: A26038358
Decision Date: 04/23/26	Archive Date: 04/23/26

DOCKET NO. 210422-154768
DATE: April 23, 2026

ORDER

Service connection for a neurocognitive disorder, to include as secondary to the service-connected celiac disease with gastroesophageal reflux disease (GERD), is granted.

FINDING OF FACT

The evidence is at least approximately evenly balanced as to whether the Veteran's neurocognitive disorder is caused by his service-connected celiac disease with GERD.

CONCLUSION OF LAW

Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a neurocognitive disorder as secondary to the service-connected celiac disease with GERD are met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from June 1978 to June 1998.

This case is before the Board of Veterans' Appeals (Board) on appeal from a February 10, 2021, Department of Veterans Affairs (VA) Regional Office (RO) rating decision.  In that decision, the RO readjudicated the previously denied claim for service connection for neurocognitive impairment as secondary to celiac disease with GERD based on receipt of new and relevant evidence, but denied the claim on the merits.

On April 22, 2021, VA received the Veteran's VA Form 10182 Decision Review Request: Notice of Disagreement (NOD).  The Veteran selected the Hearing docket.

Therefore, the Board may consider the evidence of record at the time of the RO decision on appeal, additional evidence submitted on the date of the Board hearing (including testimony), and additional evidence submitted within 90 days of the hearing.  38 C.F.R. § 20.302.

On March 12, 2025, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ).  The Veteran's spouse served as a witness during the hearing.  A transcript of that testimony is of record.

Given that the RO readjudicated the claim for a neurocognitive disorder based on receipt of new and relevant evidence and readjudication was not clearly erroneous, the Board is bound by this favorable finding.  38 C.F.R. § 3.104(c).

Service Connection

Entitlement to service connection for a neurocognitive disorder, to include as secondary to the service-connected celiac disease with GERD, unspecified depressive disorder, and/or hypothyroidism.

The Veteran contends that his neurocognitive disorder is secondary to his service-connected celiac disease with GERD and nutritional deficiencies associated with celiac disease.

Service connection for a claimed disability may be established?on a?secondary?basis if?that?disability that is due to or the result of a service-connected disease or injury.  38?C.F.R. §?3.310(a).  Establishing service connection as secondary to a service-connected disability requires a current disability that was either caused or aggravated by a service-connected disability.  38?C.F.R. §?3.310(a).  In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury.  See Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding that a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

It is the defined and consistently applied policy of the Department of Veterans Affairs to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.  38 C.F.R. § 3.102.

At the outset, the Veteran has a diagnosis of a neurocognitive disorder, first diagnosed during a September 21, 2017 VA neuropsychology consult and confirmed by a January 2018 VA examination for the central nervous system.

The Veteran more recently underwent a VA examination for the cranial nerve in
. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.  38 C.F.R. § 3.102.

At the outset, the Veteran has a diagnosis of a neurocognitive disorder, first diagnosed during a September 21, 2017 VA neuropsychology consult and confirmed by a January 2018 VA examination for the central nervous system.

The Veteran more recently underwent a VA examination for the cranial nerve in February 2021.  The February 2021 examiner concluded that the Veteran did not have a diagnosis relating to the cranial nerve.  However, the Veteran seeks service connection for neurocognitive impairment, rather than symptoms stemming from the cranial nerve, which, per the February 2021 examination report, would include symptoms such as blurry vision, double vision, facial weakness, tongue deviation, and difficulty swallowing.  As such, this examination is of no probative value as to whether the Veteran has a current neurocognitive diagnosis.  In any case, subsequent VA treatment records, such as a July 24, 2020, VA neurology consult, describe the neurocognitive impairment as "dementia."  As such, the evidence persuasively suggests that the Veteran has a current neurocognitive diagnosis.

In this case, the evidence is at least approximately evenly balanced as to whether the Veteran's neurocognitive disorder is caused by his service-connected celiac disease with GERD, unspecified depressive disorder, and/or hypothyroidism.

At the outset, the Veteran was diagnosed with celiac disease based on a biopsy taken during a May 14, 2015, enteroscopy.

Next, in a September 25, an addendum to the September 21, 2017, VA neuropsychology consult included extensive neuropsychiatric testing performed by a VA medical psychologist.  The addendum describes mental/cognitive issues such as "fogginess," short-term memory loss, losing train of thought, errors in navigation, and inability to focus, that "roughly coincided with ... diagnosis of celiac disease."  The Veteran's test results were consistent with a mild neurocognitive disorder that was "most likely [due to] a combination of celiac disease and vitamin deficiencies exacerbated by celiac disease."  The psychologist reasoned that "celiac disease has been known to be associated with 'brain fog' and other neurological sequalae, and that "vitamin deficiencies are also well documented to be associated with cognitive impairment."  The psychologist suggested that the Veteran's thyroid function may have also been a factor, though the Veteran's hypothyroidism appeared to be "controlled" as of the Veteran's most recent blood draw.  The psychologist advised that the Veteran work with a nutritionist to adjust his diet and undergo regular blood testing to screen for vitamin deficiencies.

The January 2018 VA examiner for the central nervous system opined that the Veteran's neurocognitive disorder was less likely than not proximately due to the service-connected celiac disease with GERD, hypothyroidism, and/or depression, reasoning only that "current medical literature relates cognitive disorder to both depression and hypothyroidism."  Furthermore, the examiner found that there was "no evidence to show a relation to celiac disease."

Next, a July 2019 VA psychiatric examiner disputed the September 2017 VA psychologist's opinion discussed above, finding that "the testing results did not provide specific conclusions as to the origins of the cognitive complaints, and described conclusions in rather an open manner that left more questions than answers."  The examiner concluded that the Veteran's neurocognitive disorder "arose as symptom of his SC depressive condition, which worsened in response to significant work stress."

The Veteran appears to have undergone a neuropsychiatric evaluation for C&P purposes in August 2019.  That examiner concluded that the Veteran's performance on assessments was consistent "with the early stages of a progressive dementing illness of the Alzheimer's type.  However, the examiner provided no discussion of the celiac disease, merely acknowledging that his opinion differed from that of the September 2017 VA psychologist.

Thereafter, the July 2019 psychiatric examiner submitted an addendum opinion which found that the neurocognitive disorder was less likely than not due to the service-connected celiac disease, hypothyroidism, and the depressive disorder.  However, the rationale for the opinion discussed only the depressive disorder, and found, in essence, that a secondary nexus was precluded by the diagnosis of early-onset Alzheimer's disease.

Next, of record is a July 24, 2020, VA neurology consult
 the early stages of a progressive dementing illness of the Alzheimer's type.  However, the examiner provided no discussion of the celiac disease, merely acknowledging that his opinion differed from that of the September 2017 VA psychologist.

Thereafter, the July 2019 psychiatric examiner submitted an addendum opinion which found that the neurocognitive disorder was less likely than not due to the service-connected celiac disease, hypothyroidism, and the depressive disorder.  However, the rationale for the opinion discussed only the depressive disorder, and found, in essence, that a secondary nexus was precluded by the diagnosis of early-onset Alzheimer's disease.

Next, of record is a July 24, 2020, VA neurology consult, which included a brain MRI report.  The MRI report revealed "no acute intracranial findings."  There was "very mid chronic microangiopathy," but "no significant or pattern-specific parenchymal volume loss."  The VA neurologist who performed the MRI - and also interviewed the Veteran and his wife regarding the Veteran's symptoms - concurred "with his Neuropsych evaluation with impression of 'most likely a combination of Celiac disease and vitamin deficiencies exacerbated by Celiac disease' with possible contribution of hypothyroidism."

To the extent that the February 2021 VA examiner attempted to provide an opinion regarding the cranial nerve, it is afforded no probative value because there is no cranial nerve disability at issue, and warrants no further consideration.

Finally, during the 90-day evidence window following the March 12, 2025, Board hearing, the Veteran submitted a March 2025 private medical opinion prepared by Dr. Edsel J. Comenencia, his primary care physician.  Dr. Comenencia noted review of the claims file.  Next, Dr. Comenencia noted that the Veteran had been first diagnosed with celiac disease on May 14, 2015, via an intestinal biopsy, that delay or misdiagnosis of celiac disease "can result in significant health complications, including malnutrition, neurological disorders, and other autoimmune conditions," and that the delayed diagnosis of the Veteran's case "likely contributed to progression of his condition," including as to cognitive impairment."  Dr. Comenencia described the Veteran's history of nutritional deficiencies, including as to vitamins B12 and D and folate, which were attributed to malabsorption due to celiac disease, and noted that the Veteran has long been anemic.  Supplementation had "only resulted in partial improvement."  Finally, Dr. Comenencia opined that the Veteran's neurocognitive disorder was "at least as likely as not ... secondary to his service-connected celiac disease," due to "the association between untreated or chronic celiac disease and neurological complications, including cognitive impairment."  In the Veteran's case, "the persistent inflammatory and autoimmune effects of celiac disease likely contributed to his neurocognitive disorder."

Regarding the probative value of the above evidence, the September 2017 treating VA medical psychologist conducted extensive neuropsychiatric testing of the Veteran, and provided a rationale in support of the opinion, based on apparent literature review and/or general medical principles.  Accordingly, it is afforded some probative value as to secondary nexus.

The January 2018 VA opinion's failure to consider the opinion of the September 2017 treating VA medical psychologist in finding that there was no evidence of a link between celiac disease renders it of no probative value as to secondary nexus.

Next, to the extent that the July 2019 VA psychiatric examiner attempted to discount the September 2017 opinion, the examiner did not address the merits of that opinion in any detail.  However, it should be noted that a treating VA neurologist in July 2020 as well as Dr. Comenencia in the March 2025 private opinion concurred with the September 2017 opinion in this regard.  Furthermore, it should be noted that the psychiatric examiner concluded that the neurocognitive disorder was associated with the service-connected depressive disorder, at least prior to completion of another neuropsychiatric evaluation in August 2019.  The addendum provided after the August 2019 neuropsychiatric evaluation is conclusory, merely echoing the August 2019 examiner's conclusion regarding the diagnosis of early-onset Alzheimer's disease.  Accordingly, both the July 2019 opinion and August 2019 addendum are afforded no probative value.

Regarding the August 2019 neuropsychiatric evaluation, the examining neurologist conducted extensive testing but did not explain with any particularity why the findings from this testing were consistent with early-onset Alzheimer's disease rather than another diagnosis, or why the celiac disease and associated nutritional deficiencies could still not have been associated with this diagnosis, to include through aggravation.  It should also be noted that none of the Veteran's remaining extensive VA treatment
endum provided after the August 2019 neuropsychiatric evaluation is conclusory, merely echoing the August 2019 examiner's conclusion regarding the diagnosis of early-onset Alzheimer's disease.  Accordingly, both the July 2019 opinion and August 2019 addendum are afforded no probative value.

Regarding the August 2019 neuropsychiatric evaluation, the examining neurologist conducted extensive testing but did not explain with any particularity why the findings from this testing were consistent with early-onset Alzheimer's disease rather than another diagnosis, or why the celiac disease and associated nutritional deficiencies could still not have been associated with this diagnosis, to include through aggravation.  It should also be noted that none of the Veteran's remaining extensive VA treatment records mention such a diagnosis.  Accordingly, the August 2019 neuropsychiatric evaluation, to the extent that it purported to address etiology, is afforded no probative value as to nexus.

Next, the July 2020 treating VA neurologist conducted an interview of the Veteran and his wife and performed a brain MRI, which revealed very limited findings.  Based on this evidence, the neurologist concurred with the September 2017 treating VA medical psychologist's opinion.  While no rationale accompanied the opinion, the opinion is afforded some probative value given that it relied on the neurologist's interpretation of the brain MRI.

Finally, regarding the March 2025 private opinion prepared by Dr. Comenencia, the opinion is based on review of the claims file and treatment history of the Veteran, which appears to extend for at least a decade per medical records.  Dr. Comenencia's gave a reasoned analysis of based on the Veteran's medical history, general medical principles, and pertinent literature.  Accordingly, the March 2025 opinion is also afforded some probative value.

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?

Given the above, the evidence is at least approximately evenly balanced as to whether the Veteran's neurocognitive disorder is caused by his service-connected celiac disease with GERD.  While the evidence is not conclusive in this regard, here, the positive and negative evidence are at least approximately evenly balanced.  Furthermore, it should be noted that both VA examiners and treatment providers have also suggested involvement of the service-connected depressive disorder and hypothyroidism in the Veteran's neurocognitive impairment, further supporting secondary nexus in this regard.  Accordingly, resolving all reasonable doubt in the Veteran's favor, service connection for a neurocognitive disorder is warranted.  See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 53 (1990).

 

 

L. B. CRYAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	D. Small, Attorney Advisor

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.