BVA9504329 DOCKET NO. 91-48 652 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michael P. Vander Meer, Associate Counsel INTRODUCTION The veteran served on active duty from January 1942 to September 1945. This appeal arises from a December 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. This case was last before the Board of Veterans' Appeals (Board) in January 1994, at which time it was remanded for further development. Following completion of the requested development, a rating decision entered in July 1994 continued to deny the benefit sought on appeal, and a Supplemental Statement of the Case was issued the same month. The appeal was returned to and redocketed at the Board in October 1994. The case is now ready for appellate review. CONTENTIONS OF APPELLANT ON APPEAL The appellant's primary contention is that, due to his service- connected anxiety neurosis, the veteran developed dementia in the mid-1980's, which thereafter rendered him increasingly confused and withdrawn. She states that the veteran ultimately secluded himself in a darkened room and began to eat less, which resultant weakness brought on his fatal pneumonia, and that, inasmuch as dementia is listed on the veteran's death certificate as having contributed to his death, his service-connected anxiety neurosis, to which she attributes his dementia, must be deemed to have played a role in his death. She also states that the veteran's coronary artery disease, a condition listed on the death certificate as having contributed to his death, was, in turn, attributable to his service-connected anxiety neurosis. In this regard, she directs the Board's attention to a statement from a private physician who had treated the veteran for many years for his service-connected psychiatric disability. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), following review and consideration of all evidence and material of record in the veteran's claims file, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the appellant's claim for service connection for the cause of the veteran's death. FINDINGS OF FACT 1. The immediate cause of the veteran's death in October 1990, at age 75, was sepsis syndrome, due to or as a consequence of aspiration pneumonia, "due to or as a consequence of dementia;" coronary artery disease was listed as another significant condition contributing to death but not resulting in the immediate cause of death. 2. During the veteran's lifetime, service connection was in effect for anxiety neurosis, evaluated as 30 percent disabling from November 1975, and left cervical adenopathy, evaluated as noncompensable; neither of the foregoing service-connected disabilities played a material role in producing the veteran's death. 3. An inservice episode of pneumonia was acute and transitory, resolving prior to discharge without residual pulmonary pathology. 4. Dementia was not present in service or attributable thereto. 5. Coronary artery disease was initially diagnosed many years after service and cannot be etiologically associated with service. CONCLUSIONS OF LAW 1. Neither dementia nor coronary artery disease was incurred in or aggravated by service, and the incurrence of coronary artery disease during service may not be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993). 2. A disability incurred in or aggravated by service did not cause or contribute substantially or materially to cause death. 38 U.S.C.A. §§ 1310, 5107 (West 1991); 38 C.F.R. § 3.312 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board finds that the appellant's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, the Board finds that this claim is plausible. The Board is also satisfied that all relevant facts have been properly developed, and that no further assistance to the appellant is required to comply with 38 U.S.C.A. § 5107(a). The official death certificate reflects that the veteran's death in October 1990 was caused by sepsis syndrome, due to or as a consequence of aspiration pneumonia, "due to or as a consequence of dementia;" coronary artery disease was listed as a significant condition contributing to death but not resulting in the immediate cause of death. At the time of the veteran's death, service connection was in effect for anxiety neurosis, evaluated as 30 percent disabling from November 1975, and left cervical adenopathy, evaluated as noncompensable. There is neither contention nor evidence that the latter was at all involved in the veteran's death. Under the law, service connection can be granted for any disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110. Additionally, service incurrence of coronary artery disease may be presumed if it was manifested to a compensable degree within a year of the veteran's discharge from service. 38 U.S.C.A. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable. 38 U.S.C.A. § 1113. Further, to establish service connection for the cause of the veteran's death, the evidence must show that a disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. The appellant's essential contention is that veteran's service- connected anxiety neurosis caused the dementia which was a factor in his death, thereby contributing to his death. The record shows that the veteran was hospitalized by VA in October 1975 with a one year history of transient numbness and weakness of the left side of his body. When the veteran was hospitalized at a VA facility in June and July 1984, in response to an acute myocardial infarction, the diagnoses included mild dementia. When hospitalized at a VA facility in September 1984, in response to problems including failing mental status, the diagnoses included progressive mental status deterioration of which the most likely etiology was thought to be organic brain syndrome, possibly Alzheimer's disease. When seen for VA outpatient treatment in April 1985, the veteran was assessed as having early dementia. When seen for VA outpatient treatment in November 1989, at which time the veteran was experiencing increased confusion, the assessment was multi-infarct dementia and organic mood/hallucinosis disorder. The diagnoses on the veteran's hospitalization at a VA facility in April 1990, in response to respiratory problems and chest pain, included multi-infarct dementia. When the veteran was seen in July 1990, after he had secluded himself in his bedroom with the shades pulled the previous week, the assessment was organic hallucinosis with multi-infarct dementia. In September 1990, about one month preceding his death, the related VA outpatient treatment report reflects that the veteran had dementia secondary to hypertension. When terminally hospitalized in response to respiratory problems at a VA facility in October 1990, the veteran was described as neurologically demented and mumbling intermittently. His mental status remained poor during the course of his hospitalization, and the final diagnoses included dehydration, right lower lobe pneumonia and multi-infarct dementia. Most recently, the veteran's file was reviewed by a VA psychiatrist in May 1994 for an opinion as to whether the veteran's dementia was caused by his service-connected anxiety neurosis. After noting that multi-infarct dementia is a type of organic mental disorder associated with factors including evidence of significant cerebrovascular disease, the VA psychiatrist observed that the veteran had a documented history of problems including severe arteriosclerotic cardiovascular disease and hypertension, and he stated that anxiety neurosis is not a cause or contributing factor of multi-infarct dementia. Moreover, he went on to say that neither the anxiety neurosis nor the dementia was a significant contributor to the fatal process. Thus, there is clinical doubt that dementia actually precipitated death. In any case, there is no clinical basis on this record for relating it either to service or the service-connected neurosis. The appellant further contends that the veteran's coronary artery disease, a condition listed on the death certificate as having contributed to his death, was, in turn, caused by his service- connected anxiety neurosis. In this regard, the diagnoses on the veteran's hospitalization at a VA facility in October 1975 included chronic hypertension, and in a March 1976 statement from James T. Jackson, M.D., the physician states that he treated the veteran for his service-connected nervous disorder on an intermittent basis for many years. He refers to the veteran's service-connected psychiatric disability as having "been a factor in the adverse progress of his hypertensive cardiovascular disease." When examined by VA in July 1976, the examiner alluded to the possibility, without being definitive as to any particular etiology, that the veteran's cardiovascular problems, identified as hypertension and arteriosclerosis, were related to his service-connected anxiety neurosis or to heredity or to the natural process of aging. Thereafter, the veteran was hospitalized at a VA facility in June and July 1984, during which he underwent cardiac catheterization in the aftermath of experiencing a myocardial infarction, and the pertinent diagnosis when he was again hospitalized at a VA facility in December 1984 and January 1985, in response to depression, was atherosclerotic cardiovascular disease. When hospitalized at a VA facility in response to respiratory distress in April 1990, the discharge diagnoses included congestive heart failure; and the pertinent diagnosis on the veteran's period of terminal hospitalization at a VA facility in October 1990 was coronary artery disease. Most recently, the veteran's file was reviewed by a VA cardiologist in May 1994 for an opinion as to whether the veteran's coronary artery disease was caused by his service- connected anxiety neurosis. After noting that the veteran had multiple risk factors for arteriosclerotic cardiovascular disease, including hypertension, a history of heavy smoking, elevated cholesterol and a positive family history, the physician expressed the opinion that the veteran's service-connected anxiety neurosis was not a significant predisposing factor in his development of severe, generalized arteriosclerotic cardiovascular disease. In evaluating the appellant's contention that the coronary artery disease implicated in the veteran's death was related to his service-connected anxiety neurosis, the Board has carefully considered the March 1976 statement by Dr. Jackson, wherein such service-connected disability is identified as a factor in the progress of the veteran's hypertensive cardiovascular disease. However, the Board must point out that the foregoing statement and opinion submitted by Dr. Jackson is silent for any discussion of any of the veteran's then known risk factors for atherosclerotic cardiovascular disease. In contrast, the recent opinion by the VA cardiologist specifically addressed a variety of those risk factors, and, in addition, the opinion was rendered in consideration of the entire longitudinal record. In light of the VA specialist's expertise in the field of cardiology, and because of his exhaustive review of the veteran's complete clinical history, the Board accords greater weight to his opinion. Given the foregoing observation, and inasmuch as coronary artery disease was not initially diagnosed until many years after service, and is not shown to be otherwise related to service, there is no basis to relate the coronary artery disease implicated in the veteran's death to service. Finally, with respect to the aspiration pneumonia which immediately occasioned the veteran's death, the Board notes that the veteran was hospitalized early in his service tenure, in 1942, with an episode of pneumonia which is shown, based on the report of a chest X-ray examination, to have been completely resolved in May 1942. When examined for service separation purposes in September 1945, a chest X-ray examination was negative and the veteran's lungs were clinically evaluated as normal. Inasmuch as the veteran's inservice episode of pneumonia completely resolved prior to discharge without residual pulmonary pathology, and in the absence of any evidence relating the acute aspiration pneumonia to service in any way, it becomes clear that there is no basis for associating the veteran's unfortunate demise with his active service. ORDER Service connection for the cause of the veteran's death is denied. J. J. SCHULE Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.