Citation Nr: 0006558	
Decision Date: 03/10/00    Archive Date: 03/17/00

DOCKET NO.  98-13 480	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs (VA) Regional Office (RO) in 
Phoenix, Arizona


THE ISSUE

Entitlement to special monthly compensation based on the need 
for the regular aid and attendance of another person or on 
account of being housebound.  


REPRESENTATION

Appellant represented by:	Arizona Veterans Service 
Commission


ATTORNEY FOR THE BOARD

Robert E. O'Brien, Counsel


INTRODUCTION

The veteran had periods of active service from October 1952 
to October 1956, from April 1957 to April 1969, and from May 
1984 to May 1988.  

This matter comes before the Board of Veterans' Appeals 
(Board) on appeal from a February 1997 rating decision of the 
VARO in Phoenix which denied entitlement to special monthly 
compensation based on the need for the regular aid and 
attendance of another person or by reason of being 
housebound.  

In view of the Board's decision granting entitlement to 
special monthly compensation on account of the need for 
regular aid and attendance, the issue of entitlement to 
special monthly compensation on account of being housebound 
is rendered moot.  The housebound benefit is a lesser benefit 
than the aid and attendance benefit.  See 38 U.S.C.A. 
§§ 1114(l),(s) (West 1991).


FINDINGS OF FACT

1.  Service connection is in effect for coronary artery 
disease, status post myocardial infarction, rated as 100 
percent disabling.  Service connection is also in effect for 
tinnitus, rated as 10 percent disabling; arthritis of the 
lumbosacral spine, rated as noncompensably disabling; 
bilateral high frequency hearing loss, rated as 
noncompensably disabling; sinusitis/allergic rhinitis, rated 
as noncompensably disabling; hemorrhoids, rated as 
noncompensably disabling, and hiatal hernia, also rated as 
noncompensably disabling.  

2.  The service-connected disabilities render the veteran 
unable to attend to his daily needs without the assistance of 
another person.  


CONCLUSION OF LAW

The criteria for an award of special monthly compensation 
based on the need for the regular aid and attendance of 
another person have been met.  38 U.S.C.A. §§ 1114(l), 5107 
(West 1991); 38 C.F.R. §§ 3.350, 3.352(a) (1999).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The veteran has submitted a well-grounded claim within the 
meaning of 38 U.S.C.A. § 5107(a).  Murphy v. Derwinski, 
1 Vet. App. 78, 81 (1990); Gilbert v. Derwinski, 
1 Vet. App. 49, 55 (1990).  That is, the Board finds that he 
has submitted a claim which is plausible.  The Board is also 
satisfied that all relevant evidence necessary for an 
equitable disposition of the veteran's appeal has been 
obtained and that no further assistance is required to comply 
with the duty to assist him mandated by 38 
U.S.C.A. § 5107(a).  The record shows the veteran has 
undergone several examinations to evaluate the extent and 
severity of his service-connected disabilities.  

Factual Background

The veteran is service connected for a number of 
disabilities.  Coronary artery disease, his principal 
disability, is rated as 100 percent disabling.  Tinnitus is 
rated as 10 percent disabling and he has a number of other 
disabilities each rated as noncompensably disabling.  The 
combined service-connected disability rating is 100 percent.  

A review of the evidence of record discloses that an 
examination for housebound status or permanent need for 
regular aid and attendance was accorded the veteran by VA in 
August 1996.  Chief complaints were angina and shortness of 
breath.  General appearance was described as weak.  No 
restrictions of the upper or lower extremities, trunk, spine, 
or the neck were indicated.  He was described as able to 
leave his home without assistance and to walk without the 
assistance of another person for one block.  Notation was 
made that he was receiving oxygen therapy.  The diagnoses 
were atherosclerotic coronary artery disease and severe lung 
disease.  

The veteran was accorded another examination for housebound 
status or permanent need for regular aid and attendance by 
another VA physician in March 1997.  Complaints included 
angina with inoperable coronary artery disease, memory loss, 
lightheadedness, diffuse muscle stiffness and cramps, 
anorexia, diaphoresis, dyspnea, orthopnea and paroxysmal 
nocturnal dyspnea.  The veteran was 61 years of age.  His 
height was listed as 5 feet 6 inches and his weight was 
recorded as 150 pounds.  Gait was described as slow and 
hesitant.  Posture was poor and he appeared "chronically 
ill."  The shoulders were stiff.  He dragged his right arm.  
He often assisted the right arm movement with his left hand.  
Grip strength was weak.  Sometimes he dropped things.  He 
often needed help with buttons.  Also, he needed help 
showering because of tiring easily and having shortness of 
breath.  He used a bath seat and grab bars.  

There were also joint pain and stiffness in the hips.  He 
stated the knees would give out on him.  Surgery had been 
recommended six years ago, but was ruled out because he could 
not have general anesthesia because of his heart disease.  
Knee braces and/or a cane were used to help steady his 
balance.  He had been advised to be very careful, because a 
fall could be devastating.  

Trunk and spinal pain was described as extreme.  He could not 
bend over completely.  He could not get up without holding 
onto something.  Sometimes he required assistance.  

It was indicated he could walk without the assistance of 
another person for one block.  It was noted that he stopped 
for rest secondary to his angina.  

The examination diagnoses were ischemic cardiomyopathy with 
congestive heart failure with related complications and 
osteoarthritis of multiple joints.  

Notation was made that regardless of how he felt, he got up 
and got himself dressed.  He always had several projects 
going.  He was striving to keep himself mentally and 
physically active.  He always tried to do some exercise and 
stretching.  He never left the house alone.  He seldom drove.  
He needed help getting his electric cart out of the van.  He 
took rest periods during the day and dozed frequently.  
Nighttime was very hard on him.  He had shortness of breath.  
He choked while in a reclining position and slept with his 
head elevated.  He needed help sitting up when choking.  Most 
of the time he stated he was up and down until around 4 a.m., 
and then would get up at 8 or 9 a.m.  It was stated that he 
needed an air circulator at all times.  It was also indicated 
he did not leave home on a daily basis.  He never left his 
home unattended.  Level of energy and well-being dictated 
whether or not he left his home.  

He used knee braces and/or a cane for balance and locomotion.  
These aids did not compensate for tiring and shortness of 
breath.  He was on an extreme amount of medication for his 
heart condition.  The diagnoses were atherosclerotic coronary 
disease, congestive heart failure, enlarged abdominal aorta, 
fibromyalgia, and degenerative joint disease.  His condition 
was described as permanent and progressive, and it was opined 
that he required assisted care most of the time on a 
permanent basis.  

The veteran was accorded another examination for aid and 
attendance or housebound status by another VA physician in 
November 1997.  The claims file was reviewed by the examiner 
prior to the examination.  The veteran was accompanied to the 
examination by his wife since he was unable to drive and was 
dependent on others for transportation.  Reportedly, he was 
confined to an electric wheelchair when out of his house.  He 
took a total of 28 different medications which his wife set 
out for him.  

He was able to dress himself, providing he was in no hurry, 
but he stated he was unable to tie his shoes.  He was able to 
take showers, but indicated his wife had to dry him since he 
was unable to raise his right arm above shoulder level.  He 
could take care of his own hygiene, but required assistance 
getting on and off the toilet.  Around the house he used 
either a walker or a cane and was very unstable on his feet.  
He related that he could walk about 50 feet before becoming 
dyspneic.  He slept with his head elevated and was on a low 
salt, low fat diet.  He indicated that whenever he fell, he 
needed assistance in getting up.  He was not able to do any 
housework and was dependent upon his wife for his food and 
laundry.  

On examination he was described as alert and cooperative.  
His last recorded weight was 160 pounds.  He was able to 
stand, but appeared extremely unstable when doing so.  There 
seemed to be a full range of motion of the entire spine with 
no areas of tenderness noted.  He appeared to have full range 
of movement of the left shoulder, but the right shoulder was 
limited to 85 degrees in forward flexion and to 85 degrees in 
abduction.  This was due to pain in the right shoulder.  
Moderate tenderness was elicited to palpation of the bursa on 
the right.  

A full range of motion of the upper extremities was 
indicated.  There appeared to be no motion restriction of the 
hips.  The veteran wore knee braces on both knees.  Moderate 
crepitation was noted in both knees, but the knees appeared 
to be reasonably stable.  Pain was elicited on movement of 
both knees.  There was tenderness to palpation of both lower 
extremities, with two-plus edema of both lower legs, worse on 
the left.  The impressions were:  Status post myocardial 
infarction with marked residuals; congestive heart failure; 
bursitis of the right shoulder; degenerative joint disease, 
both knees, marked; and rash of unknown etiology on the back.  

Of record are reports of VA outpatient visits on periodic 
occasions between 1996 and 1998.  At the time of one such 
visit in September 1998, it was indicated the veteran had 
multiple severe medical problems "that seem in my mind to 
make the pt an appropriate candidate for A plus A."  Notation 
was also made that the veteran was depressed, a fact which 
was understandable in light of his various conditions.  

Also of record is a communication apparently signed in 
October 1998 by the physician who conducted the 
aforementioned outpatient visit.  It was to the effect that 
the veteran was 100 percent service connected for heart 
disease, a condition which the physician described as 
"progressive and permanent."  Notation was made that the 
veteran's wife had been instructed by various staff members 
at the VA Medical Center in Tucson on how to attend to the 
veteran's needs.  The veteran was described as "substantially 
confined to his home and is unable to leave his home 
unattended."  The physician opined that if the veteran did 
not have a caregiver at home, he would have to live in an 
upper level assisted living facility with night care.

In a statement dated in April 1999, the veteran reported that 
his congestive heart failure had caused him to experience a 
memory deficit and to require assistance with all activities 
of daily living.  He also reported that he spent most of his 
time in bed, and required help in bathing, dressing, and that 
sometimes he lacked the energy to get to the bathroom and 
experienced incontinence.

The physician who saw the veteran in October 1998, reported 
on follow-up in June 1999, that the veteran complained of 
marked foot pain.  An assessment was made of metatarsalgia.  
The physician opined that the veteran "clearly" needed help 
at home because of chronic congestive heart failure, 
shortness of breath, and dyspnea on exertion due to 
cardiomyopathy.  He added that the veteran was currently 
receiving Hospice care, and needed help with daily needs.  It 
was noted that the veteran was currently receiving hospice 
care.  

The physician added that the veteran had end stage ischemic 
cardiomyopathy and chronic congestive heart failure and was 
currently in receipt of home hospice care for his end stage 
illness.

Criteria

Special monthly compensation may be paid to a veteran who, by 
reason of service-connected disabilities, is permanently 
bedridden or so helpless as to be in need of regular aid and 
attendance of another person.  38 U.S.C.A. § 1114(l); 
38 C.F.R. § 3.350(b).

The basic criteria for regular aid and attendance and 
permanently bedridden include the following:  Inability of 
claimant to dress or undress himself, or to keep himself 
ordinarily clean and presentable; frequent need of adjustment 
of any special prosthetic or orthopedic appliances which by 
reason of the particular disability cannot be done without 
aid  (this will not include the adjustment of appliances 
which normal persons would be unable to adjust without aid, 
such as supports, belts, lacing at the back and so forth); 
inability of claimant to feed himself through loss of 
coordination of upper extremities or through extreme 
weakness; inability to attend to the wants of nature; or 
incapacity, physical or mental, which requires care or 
assistance on a regular basis to protect the claimant from 
hazards or dangers incident to his or her daily environment.  
"Bedridden" will be a proper basis for the determination.  
For the purpose of this paragraph "bedridden" will be that 
condition which, through its essential character, actually 
requires that the claimant remain in bed.  The fact that the 
claimant has voluntarily taken to bed or that a physician has 
prescribed rest in bed for the greater or lesser part of the 
day to promote convalescence or cure will not suffice.  It is 
not required that all of the disabling conditions enumerated 
in this paragraph be found to exist before a favorable rating 
may be made.  The particular personal functions which the 
veteran is unable to perform should be considered in 
connection with his or her condition as a whole.  It is only 
necessary that the evidence establish that the veteran is so 
helpless as to need regular aid and attendance, not that 
there be a constant need.  Determinations that the veteran is 
so helpless as to be in need of regular aid and attendance 
will not be based solely upon an opinion that the claimant's 
condition is such as would require him or her to be in bed.  
They must be based on the actual requirements of personal 
assistance from others.  38 C.F.R. § 3.352(a).

Eligibility for aid and attendance requires that at least one 
of the enumerated factors of 38 C.F.R. § 3.352(a) be present.  
Turco v. Brown, 9 Vet. App. 222 (1996) 


Analysis

In this case, the record shows that the veteran has undergone 
several special VA aid and attendance examinations.  At the 
time of one such examination in March 1997, the examiner 
opined that the veteran's condition was permanent and 
progressive and required assisted care the majority of the 
time on a permanent basis.  More recently, another VA 
physician stated in September 1998 that the veteran's 
multiple severe medical problems seemed to make him an 
appropriate candidate for aid and attendance.  In June 1999 
that same physician stated that the veteran clearly needed 
help at home due to chronic congestive heart failure, 
shortness of breath, and dyspnea on exertion due to 
cardiomyopathy.  He specifically stated that the veteran 
needed help with daily needs.  The undersigned notes that 
there is no competent evidence offering a contrary medical 
opinion.  

The unrefuted evidence is that the veteran requires 
assistance with activities of daily living, including 
dressing, attending to the wants of nature, and basic 
hygiene; and that such assistance is being provided by the 
veteran's spouse and by hospice workers.  The statements from 
the VA physicians suggest that the need for such assistance 
is the result of his service-connected heart disease.  
Accordingly, entitlement to special monthly compensation 
based on the need for the regular aid and attendance of 
another person is established.  38 U.S.C.A. § 1114(l); 
38 C.F.R. §§ 3.350, 3.352(a).  



ORDER

Entitlement to special monthly compensation based on the need 
for the regular aid and attendance of another person is 
granted, subject to the laws and regulations governing the 
award of monetary benefits.  




		
	Mark D. Hindin
	Member, Board of Veterans' Appeals