In my last blog I discussed how a veteran can provide necessary documentation for the VA to initiate an evaluation for a cognitive dysfunction if there is suspicion that one exists. A cognitive dysfunction can arise from a reversible condition such as acute sleep issues, or uncontrolled blood sugars stemming from diabetes mellitus. These transient symptoms of cognitive dysfunction are treatable and typically abide once the underlying condition is treated. However, if the veteran is diagnosed with some form of cognitive impairment that is not transient in nature and is found to be related to service and is later granted service connection for that condition, the next step in the process is to determine the severity of that condition and more specifically, how it is rated by the VA. That is, to determine the assessment of level of cognitive dysfunction as it is evaluated in the rating of impairments.
The VA lumps all cognitive disorders, with the exception of traumatic brain injury, including all of the following conditions under one General Rating Formula for Mental Disorders:
- Dementia due to infection (HIV infection, syphilis, or other systemic or intracranial infections)
- Dementia due to head trauma
- Vascular dementia
- Dementia of unknown etiology
- Dementia of the Alzheimer’s type
- Dementia due to other neurologic or general medical conditions (endocrine disorders, metabolic disorders, Pick’s disease, brain tumors, etc.), or that are substance-induced (drugs, alcohol, poisons)
- Organic mental disorder, other (including personality change due to a general medical condition)
First, I want to discuss some of the functional deficits associated with these conditions so that you can see how the VA’s decision of limiting the evaluation of these conditions under the rating formula for mental disorders, alone, is a disservice to veterans and their families.
Functional deficits for these conditions vary from mild, to severe, to total impairment. A veteran may initially exhibit difficulty performing activities of daily living. The veteran’s level of observed cognitive dysfunction is seen as mild. For example, a veteran who is complaining of some memory lapses that create annoyance and hassles but doesn’t have a significant loss of function outside of simply misplacing things, or forgetting an anniversary or birthday.
However, the symptoms may progressively worsen where there is concern for safety. At this level, the level of dysfunction is more severe, moderate or severe. For example, the veteran may report short-term memory loss, decreased efficiency that worries family or that may threaten their job, new activities may become problematic; these are signs of significant functional difficulties. Signs of more severe symptoms include problems with executing their daily routine, they’re exhibiting odd behavior in speech or mood, or there are obvious safety risks. In talking to a veteran, he described how he was on his way to a doctor’s office, and had missed the exit on the highway. Not comprehending the dangers, he put his car in reverse and backed his vehicle up in the middle of traffic to get back to his missed exit. This is an overt sign of severe impairment that impacts the safety of not only the veteran but families, and others around them.
Difficulties that directly impact things such as self-awareness, judgment, problem solving and decision making could raise concerns and should be seen as severe functional impairments.
When evaluating a cognitive impairment, other than TBI, however, the VA uses the General Rating Formula for Mental Disorders. This rating is inclusive of all affective disorders as well, such as posttraumatic stress disorder, major depressive disorder, anxiety disorder and the like.
Under this rating formula, for a veteran to be granted 100% service-connected compensation for let’s say, dementia, would have to meet the following criteria:
Total occupational and social impairment, due to such symptoms as:
- gross impairment in thought processes or communication
- persistent delusions or hallucinations
- grossly inappropriate behavior
- persistent danger of hurting self or others
- intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene)
- disorientation to time or place
- memory loss for names of close relatives, own occupation, or own name
It is very difficult for a veteran to meet the stringent criteria for total occupational and social impairment under this rating formula. For example, “memory loss for names of close relatives, own occupation, or own name”, occurs during very advanced, end-stage dementia. Under the rating formula for cognitive impairments, however, used only for TBI cases, a veteran is warranted a 100% rating if:
Total ——- Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment.
Under this rating formula, a veteran is able to attain a 100% rating if testing has shown severe impairment in memory, attention, concentration or other executive functions. They don’t have to show that they can’t remember their own name, just show severe memory impairment on testing.
Further, the TBI rating formula has provisions for a veteran to attain total impairment under two categories not mentioned in the rating formula for mental disorders: Visual spatial orientation, and motor activity. Both of which is common in dementia and Alzheimer’s. Veterans may experience difficulty swallowing foods and liquids, loss of muscle function, and frequent falls due to the loss of visual spatial capabilities. These motor activities are not addressed in the rating for mental disorders.
It is my opinion, that a veteran who has been diagnosed with any severe cognitive impairment that causes total occupational and social impairment to meet any of the facets under the TBI rating formula should be granted that rating even if they do not have TBI. It is capricious to not extend this rating formula to other cognitive impairments.