RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

SEPARATION DATE:  20060210 

 
NAME:  XXXXXXXXXXXXX                                                                        BRANCH OF SERVICE:  ARMY 
CASE NUMBER:  PD1101110 
BOARD DATE:  20121025 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered individual (CI)  was a National Guard SPC/E-4 (19K10/M1 Armor Crewman) medically 
separated  for  dementia.    He  was  also  diagnosed  with  alcohol  dependence  disorder  and  was 
hospitalized on three occasions for alcohol detoxification and treatment.  He suffered at least 
two closed head injuries and had one skull fracture due to a fall.  He could not be adequately 
rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or 
satisfy physical fitness standards.  He was consequently issued a permanent P3/S3 profile and 
referred for a Medical Evaluation Board (MEB).  The MEB determined alcoholism as medically 
unacceptable IAW AR 40-501 and identified the diagnosis of depressive disorder, not otherwise 
specified  (NOS).    These  were  the  only  two  conditions  forwarded  to  the  Informal  Physical 
Evaluation Board (IPEB) for adjudication.  The IPEB adjudicated both conditions as dementia, in 
the  setting  of  long-term,  serious  alcohol  usage  with  multiple  head  traumas,  as  unfitting  and 
rated at 10% based on the Veteran’s Administration Schedule for Rating Disabilities (VASRD).  
The CI appealed to a Formal PEB (FPEB) which then adjudicated his condition as existing prior to 
service  (EPTS)  and  non-compensable.    The  CI’s  case  was  then  reviewed  by  a  Formal 
Reconsideration PEB that rated his dementia at 10% based on the VASRD and, he was medically 
separated with a 10% disability rating. 
 
 
CI CONTENTION:  “Because I was rated at 100% by VA.” 
 
 
SCOPE  OF  REVIEW:    The  Board  wishes  to  clarify  that  the  scope  of  its  review  as  defined  in 
Department of Defense Instruction (DoDI) 6040.44 (Enclosure 3, paragraph 5.e.2) is limited to 
those conditions which were determined by the PEB to be specifically unfitting for continued 
military  service;  or,  when  requested  by  the  CI,  those  condition(s)  “identified  but  not 
determined to be unfitting by the PEB.”  The ratings for unfitting conditions will be reviewed in 
all cases.  Any conditions or contention not requested in this application, or otherwise outside 
the Board’s defined scope of review, remain eligible for future consideration by the Army Board 
for Correction of Military Records. 
 
 
RATING COMPARISON: 
 

Service Recon FPEB – Dated 20060106 

VA (2 Mo. After Separation) – All Effective Date 20060211 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Condition 

Dementia, in the Setting 
of Long-Term, Serious 
Alcohol Usage with 
Multiple Head Traumas 

8045-9304 

10% 

9304 

100%* 

20060417 

Residuals of Multiple Head 
Traumas with Dementia and 
Depression 
Degenerative Joint Disease, 
Right Hip 
Left Hip Strain with 
Degenerative Joint changes 

5252 

5252 

10% 

10% 

20060914 

20060914 
20060914 

0% X 1 / Not Service-Connected x 4 

Combined:  100% 

↓No Additional MEB/PEB Entries↓ 

Combined:  10% 

*100% rating continued through last rating decision available, 20110916. 
 

ANALYSIS SUMMARY:  The Board notes the current VA ratings for all of his service-connected 
conditions, but must emphasize that its recommendations are premised on severity at the time 
of  separation.    The  VA  ratings  which  it  considers  in  that  regard  are  those  rendered  most 
proximate to separation.  The Disability Evaluation System (DES) has neither the role nor the 
authority  to  compensate  service  members  for  anticipated  future  severity  or  potential 
complications of conditions resulting in medical separation.  That role and authority is granted 
by Congress to the Department of Veterans’ Affairs (DVA). 
 
Dementia Condition.  The narrative summary (NARSUM) prepared 9 months prior to separation 
noted two major factors related to the condition that resulted in the CI’s medical separation.  
The first factor was an alcohol dependence disorder that required three hospitalizations over 
the CI’s military career with the most recent hospitalization occurring in September 2004.  At 
the time the NARSUM was prepared, the CI was alcohol free and in a sustainment program at 
the local military treatment facility.  The second issue was the CI’s history of “traumatic events 
to his central nervous system.”  There were three episodes of head trauma documented; two 
were  “covered”  with  line  of  duty  determinations  and  another  occurred  while  the  CI  was  at 
home on “convalescent leave.”  This last head injury mentioned in the NARSUM resulted in a 
temporal bone fracture.  A magnetic resonance imaging (MRI) scan was accomplished in August 
2003  and  revealed  left  temporal  cyst  and  a  left  superior  convexity  encephalomalacia  with 
associated gliosis left temporal lobe, “which is felt most likely to be due to traumatic events.”  
The CI had also been diagnosed with depression and had been treated with various medications 
but was taking Remeron 30 milligrams at bedtime and Klonopin on an as needed basis.  Physical 
exam  was  significant  for  mini-mental  state  exam  of  30/30  and  a  normal  neurological  exam.  
“The  patient  has  presently  been  undergoing  this  Medical  Evaluation  Board  process  for 
approximately  one  and  three  quarter  years.  His  mental  status  and  impairment  seem  to  be 
stable.”    At  the  MEB  exam  prepared  approximately  8  months  prior  to  separation,  the  CI 
reported “too many hits in the head from Army tanks & trucks,” “can’t remember things like I 
used to” and “hit in head with a 5 ton tailgate.”  The MEB physical exam noted “depression” in 
the physical exam portion of the exam form and “… history of depression for several years and 
alcohol abuse for many years.  Pt. has been alcohol free for 1 year now.”  The MEB psychiatric 
addendum prepared approximately 5 months prior to separation documented that the CI had 
been compliant with outpatient psychiatric treatment, maintained alcohol sobriety, followed up 
regularly  with  the  substance  abuse  rehabilitation  department  and  continued  in  outpatient 
psychiatric follow-up.  He continued to complain of depressive symptoms with recent stressors 
of  divorce  and  child  custody  issues.    He  reported  compliance  with  current  outpatient 
medication regimen of Cymbalta 60mg by mouth every day, Remeron 30mg by mouth every 
night  at  bedtime,  Klonopin  .5  every  day  and  Antabuse  250mg  by  mouth  every  day.    He 
discontinued  his  Aricept  (indicated  in  the  treatment  of  Dementia)  secondary  to  side  effect 
problems. The CI had also had multiple trials of other antidepressant medications with limited 
success  or  side  effect  problems.    Mini-Mental  status  examination  performed  in  August  2005 
was 26/30.  Patient repeated neuropsychological testing in June 2005 and it was consistent with 
previous  testing  performed 
intellectual 
functioning,  borderline  to  low  average  memory  functioning,  significant  impairment  in  visual 
perceptual organization and significant depression.  The worsening memory loss can be more 
readily  accounted  for  by  increased  depression.    The  psychiatrist  noted  Axis  I  diagnoses  of 
depressive disorder, NOS; dementia manifested by neuropsychological findings consistent with 
organicity  and  visual  perceptual  organization,  borderline 
intellectual  functioning,  and 
borderline  to  low  average  memory  functioning;    and  alcohol  dependence  with  physiological 
dependence in full remission.  His current GAF was 65.  The psychiatrist opined the CI did not 
meet retention standards but was competent and able to manage his own finances.  
 
The  VA  Compensation  and  Pension  (C&P)  exam  prepared  approximately  2  months  after 
separation  noted,  “Due  to  significant  memory  problems  and  other  impairments  in  cognitive 
functioning, Mr. Lewis did not provide a clear chronology of his military service.”  In reference 

  Results  showed  borderline 

in  January  2004. 

   2                                                           PD1101110 
 

to the CI’s reported history of duty and experiences in Iraq, a VA regional office requested a 
review  of  the  history  performed  on  the  17  April  2006  VA  C&P  examination.    That  review 
determined that the CI significantly misrepresented the facts about his duty and experiences 
while he was on active duty from 3 September 2002 to 10 February 2006 and therefore, the 
diagnosis of Posttraumatic Stress Disorder (PTSD) was not valid.  The 17 April 2006 C&P exam 
was significant for the following findings: He was oriented to person, place, time, and situation.  
He had a flattened affect.  The CI “…was  currently helping mother and one brother with the 
operation of a mobile home trailer park.  Was a county employee for many years prior to taking 
leave for his National Guard service.  He rambled circumstantially and tangentially throughout 
the  interview,  gave  excessive  details,  and  required  repeated  redirection.    He  has  lived  alone 
since his divorce approximately eight years ago.  He lives near his mother and has daily contact 
with  her.    Mr.  L---  appears  to  live  a  socially  isolated  life.    Given  the  consistent  and  broad 
problems with cognitive functioning that Mr. L--- demonstrated in this interview, it is hard to 
image  him  functioning  effectively  in  the  work  place.”    The  examiner  noted  that  the  CI  had 
significant  depression  and  the  symptoms  of  depression  that  he  manifested  can  also  be 
symptoms  of  PTSD.  He  opined  the  CI’s  cognitive  impairment  most  likely  resulted  from  a 
combination of head trauma, depression, and possible effects of alcohol. His current GAF was 
60.    His  condition  continued  to  deteriorate  over  time  and  by  July  2008  he  was  declared 
incompetent for the purpose of managing VA payments and his sister was appointed to handle 
his funds.   
 
The Board directs attention to its rating recommendation based on the above evidence.  After 
US  Army  Physical  Disability  Agency  (USAPDA)  formal  reconsideration  review,  the  final 
adjudication  was  Dementia,  in  the  setting  of  long-term,  serious  alcohol  usage  with  multiple 
head traumas coded analogously as 8045-9304 and rated 10%.  The VA applied the 9304 code 
for residuals of multiple head traumas with dementia and depression and evaluated it at 100% 
citing  total  occupational  and  social  impairment  due  to  symptoms  of  gross  impairment  of 
thought process and communication.  Although there are significant alcohol dependence issues 
in this case, there is no defensible basis for applying, or means of measuring, any deduction 
which  might  be  considered  and  to  do  so  would  require  resorting  to  speculation.    The  Board 
must therefore disregard the influence of alcohol abuse on ratable symptoms for its permanent 
rating  recommendation.    In  addition,  the  USAPDA’s  reconsideration  review  overturned  the 
FPEB’s  determination  of  “existed  prior  to  service”  in  reference  to  the  CI’s  condition  thus 
establishing  the  condition  as  unfitting  and  compensable,  which  must  be  adjudicated  IAW 
VASRD guidelines in effect at the time of separation.  In accordance with §4.124a Schedule of 
ratings—neurological conditions and convulsive disorders, the USAPDA’s use of the 9304 code 
limited the evaluation to 10% if the diagnosis of multi-infarct dementia associated with brain 
trauma  is  not  present,  as  in  this  case.    The  CI  was  also  diagnosed  and  treated  with  various 
medications  for  depression  and  dementia.    The  use  of  §4.130  Schedule  of  ratings—mental 
disorders  could  also  be utilized  in  this  case  allowing  the  Board  to  base  its  coding  and  rating 
recommendation on the totality of symptoms manifested by the CI at the time of separation 
using  the  General  Rating  Formula  for  Mental  Disorders.    The  Board  spent  considerable  time 
discussing the many significant details present in this case related to the CI’s mental symptoms 
and capabilities, circumstances surrounding the various head injuries, administrative processes 
and the various evaluation tools utilized by the mental health professionals.  The Board also 
spent considerable time deliberating the merits of each of the coding and rating options noted 
above and reached the conclusion that significant value was to be placed on the findings of the 
DES  process  that  included  adjudication  from  the  reconsideration  PEB.    That  adjudication 
followed the rating guidance present in VASRD §4.124a for the coding scheme utilized at the 
time of separation and it was judged to be not incorrect.  After due deliberation, considering all 
of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there 
was  insufficient  cause  to  recommend  a  change  in the  formal  reconsideration  adjudication  of 
the  dementia,  in  the  setting  of  long-term,  serious  alcohol  usage  with  multiple  head  trauma 
condition. 

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BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or 
guidelines relied upon by the PEB will not be considered by the Board to the extent they were 
inconsistent  with  the  VASRD  in  effect  at  the  time  of  the  adjudication.    In  the  matter  of  the 
dementia,  in  the  setting  of  long-term,  serious  alcohol  usage  with  multiple  head  traumas 
condition,  the  Board,  by  a  simple  majority,  recommends  no  change  in  the  PEB  adjudication.  
The  single  voter  for  dissent,  who  recommended  rating  9304-9435  at  50%,  submitted  the 
appended minority opinion.  There were no other conditions within the Board’s scope of review 
for consideration. 
 
 
RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of 
the CI’s disability and separation determination, as follows: 
 

VASRD CODE 
8045-9304 
COMBINED 

RATING 

10% 
10% 

UNFITTING CONDITION 

Dementia, in the Setting of Long-Term, Serious Alcohol Usage 
with Multiple Head Traumas 

 
 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20111202, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 
 
 
 
 
 
 

 

           XXXXXXXXXXXXXXXXXXXX 
           President 
           Physical Disability Board of Review 

   4                                                           PD1101110 
 

MINORITY OPINION 

 
The Record of Proceedings (ROP) above states that the coding and rating scheme used by the 
Physical  Evaluation  Board  (PEB)  was  not  incorrect.    However,  it  was  incorrect  and  does  not 
comply  with  paragraph  §4.126  (d)  of  the  Veteran’s  Administration  Schedule  for  Rating 
Disabilities  (VASRD)  in  effect  at  the  time  of  separation.    The  Physical  Evaluation  Board  (PEB) 
determined  this  covered  individual  (CI)  was  unfit  for  continued  military  service  due  to 
“Dementia,  in  the  setting  of  long-term,  serious  alcohol  usage  with  multiple  head  trauma.  
Dementia  is  associated  with  a  depressive  disorder,  NOS  for  which  the  Soldier  takes  anti-
depressant  medications,  and  alcoholism  is  currently  in  total  remission.”    The  VA  service-
connected “residuals of multiple head traumas with dementia and depression.”  Both the VA 
and the PEB noted dementia, depression, and multiple head traumas.  Neither the PEB nor the 
VA made any deductions for the effects of the alcoholism or any pre-service condition.   
 
As  described  in  the  ROP  above,  the  VASRD  includes  rating  criteria  for  dementia  in  both 
paragraph §4.124a Schedule of Ratings--Neurological Conditions and Convulsive Disorders and 
paragraph §4.130 Schedule of Ratings—Mental Disorders.  In general, dementia can be rated 
using either paragraph. However, VASRD §4.126 (d) states:  “When a single disability has been 
diagnosed  both  as  a  physical  condition  and  as  a  mental  disorder,  the  rating  agency  shall 
evaluate it using a diagnostic code which represents the dominant (more disabling) aspect of 
the condition (see §4.14).”  Paragraph §4.14 Avoidance of Pyramiding is an instruction to avoid 
rating the same disability under various diagnoses.  This prohibits two separate ratings, with 
one utilizing §4.124a and one utilizing §4.130.  Additionally, using §4.124a does not incorporate 
the associated depression specifically mentioned by both the PEB and the VA. 
 
The  CI’s  dementia  can  be  viewed  as  either  a  physical  condition  or  a  mental  disorder.    The 
dominant or more disabling aspect of the CI’s dementia is the significant cognitive dysfunction 
documented  on  two  separate  and  valid  neuropsychological  testing  events  and  it  should  be 
rated as a mental disorder IAW §4.126 (d).  The CI does not merely have the less consequential 
mild or even moderate cognitive impairments associated with a post-concussive syndrome or 
traumatic  brain  injury  as  the  2005  VASRD  code  8045  would  cover.    He  has  significant,  life-
altering cognitive impairments that will likely prevent him from gainful employment for the rest 
of  his  life.    In  fact,  the  rating  criteria  for  8045  has  been  changed  over time  to  afford  higher 
disability ratings for Veterans with more significant cognitive impairments.  If the CI’s condition 
was rated using the current 8045 rating criteria, a minimum rating of 70% would be warranted 
if  his  impairment  was  considered  moderate.    However,  his  cognitive  impairment  is  more 
accurately  described  as  severe  and  this  would  warrant  a  100%  rating.    The  current  rating 
criteria for 8045 also states that emotional/behavioral dysfunction should be evaluated under 
§4.130 when there is a diagnosis of a mental disorder.  The current 8045 code is to be used to 
evaluate emotional/behavioral symptoms only when there is no diagnosis of a mental disorder.  
However, this rating criteria was not in effect when the CI separated from service in February 
2006 and a rating greater than 10% cannot be assigned under code 8045. Additionally, the 10% 
limit imposed by the VASRD rating criteria for 8045 in effect at the time of separation does not 
accurately reflect the level of functional impairment caused by the dementia.  
 
The utilization of §4.130 to rate the CI’s dementia as a mental and not a physical disorder is not 
only required in order to comply with section §4.126 (d) from the VASRD in effect at the time of 
separation,  it  also  allows  a  disability  rating  more  commensurate  with  his  actual  level  of 
functional impairment.  It also incorporates the associated depression which was acknowledged 
by both the PEB and the VA to contribute to his overall impairment.  Additionally VASRD §4.7 
Higher of two evaluations directs that when there is a question as to which of two evaluations 
shall  be  applied,  the  higher  evaluation  will  be  assigned  if  the  disability  picture  more  nearly 
approximates the criteria required for that rating.  As just described, the CI’s disability picture 

   5                                                           PD1101110 
 

more nearly approximates the criteria required for rating the dementia as a mental illness using 
§4.130.  
 
The initial VA C&P examination provided the Board with the best picture of the CI’s disability 
that can be used for rating purposes as there was salient information present that was based 
solely  on  the  examiner’s  observations.    This  examination  documented  the  findings  of 
circumstantial  speech,  impaired  short  and  long  term  memory,  mood  disturbance,  socially 
isolated  life,  flattened  affect,  low  energy,  difficult  social  relationships  and  an  examiner’s 
statement  of  “Given  the  consistent  and  broad  problems  with  cognitive  functioning  that  Mr. 
Lewis demonstrated in this interview, it is hard to image him functioning effectively in the work 
place.”    The  CI  was  working  in  the  family  business  helping  his  mother  and  brother  manage 
trailer park at the time of separation.  While the record does not include any information about 
his  level  of  functioning  in  this  position,  this  appears  to  have  been  a  protected  environment 
without any significant responsibilities or demands.  There was no evidence of the impairment 
of impulse control, neglect of personal hygiene, inability to function independently, or spatial 
disorientation  in  evidence  that  would  support  the  next  higher  rating  of  70%  in  the  General 
Rating Formula for Mental Disorders.  This Board member therefore recommends a disability 
rating  of  50%  for  the  dementia  and  depression,  in  the  setting  of  long-term,  serious  alcohol 
usage with multiple head traumas condition based on occupational and social impairment with 
reduced reliability and productivity. 
 
 

VASRD CODE 
9304-9435 
COMBINED 

RATING 
50%  
50% 

UNFITTING CONDITION 

Dementia and Depression, in the Setting of Long-Term, Serious 
Alcohol Usage with Multiple Head Traumas 

 
 
 
 
 
 
 

 

   6                                                           PD1101110 
 

 
 

 
 
 

 
 
 

 
 
 

 
 
 

 
 

 
 
 

SFMR-RB 
 
 
 
 
MEMORANDUM FOR Commander, US Army Physical Disability Agency  
(TAPD-ZB /  ), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557 
 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation  
for XXXXXXXXXXXXXXXXXXXXXXX, AR20120021211 (PD201101110) 
 
I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD 
PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under 
the authority of Title 10, United States Code, section 1554a,   I accept the Board’s 
recommendation and hereby deny the individual’s application.   
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress 
who have shown interest in this application have been notified of this decision by mail. 
 
BY ORDER OF THE SECRETARY OF THE ARMY: 
 
 
 
 
Encl 
 
 
 
CF:  
(  ) DoD PDBR 
(  ) DVA 
 

       XXXXXXXXXXXXXXXXXXXXXXX 
       Deputy Assistant Secretary 
           (Army Review Boards) 

 
 
 

   7                                                           PD1101110