For Agent Use Only. Not for Use with the Public. Underwriting the Elderly Cas Pengelley General...

For Agent Use Only. Not for Use with the Public.

Underwriting the Elderly

Cas PengelleyGeneral Director, Life UnderwritingApril 2013

Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02116 (not licensed in New York) and John Hancock Life Insurance Company of New York, Valhalla, NY 10595. Insurance policies and/or associated riders and features may not be available in all states. © 2013 John Hancock. All rights reserved. MLINY

For Agent Use Only. Not for Use with the Public.2 of 41

Agenda

• Introduction• Underwriting Older Ages• Common Examination Tools• Conclusions• Questions


Are these Older Age Applicants Insurable?


Population Trends


Causes of Death


Pearls: Vitality, Energy, Dexterity & Strength

• Education closely related to lifetime income

• Better educated = better health = lower risk of disability

• Health at age 65*:– 80% have at least one chronic health condition– 50% have at least two– 30% have three or more chronic diseases*

• How are their vitality, energy, dexterity and strength (VEDS)?

* US Census Bureau, Current Population Reports, pp. 23-209, 65+ in the United States, 2005


Underwriting Considerations


Underwriting

• Do we underwrite the older age applicant like any other applicant?


What to Expect as “Normal”

Cartoon used with permission from www.CartoonStock.com


What to Expect As “Normal” (cont’d)

• Slower reflexes

• “Hardening of the arteries”

• Decrease in renal function, liver function, lung capacity

• Depressed immune system, more susceptible to infections

• “Benign forgetfulness”


What are the Red Flags?

• Underlying/pre-existing disease

• Weight loss

• Depression and withdrawal from outside activities

• Memory loss

• Mobility issues

• Falls


Good, Bad, Ugly

• Good:– Routine medical care

– Cognitive functioning

– Activities (work, volunteer, travel)

– Build (BMI 22-26)

– Serum albumin (> 4.2gm/dl)


Good, Bad, Ugly

• Bad:– Sporadic medical care, lack of follow-up

– Cognitive dysfunction (some impairment)

– Limited activities – fall history

– Build, loss of weight – co-existence depression

– Serum albumin (<3.8gm/dl)


Good, Bad, Ugly

• Ugly:– No medical care within the last 2 years

– Cognitive impairments – family concerns

– No outside activities – fall history with fractures or significant injuries

– Build – loss of more than 10% body weight within the last six months

– Serum albumin (< 3.5gm/dl)


Gathering of Information

• Listing of all doctors, including specialists (type) – be aware of dual residence

• Listing of all medications

• Last visits, why (routine, referral)

• History, diagnosis, treatments

• Areas of focus– General health– Cognition and functional status– Favorable VEDS


Common Examination Tools


Tools Commonly Used

• Older age examination

• Cognitive assessment screening (MMSE)

• Serum albumin

• Pulmonary function tests (PFTs)

• Glomerular Filtration Rate (eGFR)


Older Age Examination

• Older age examination includes:– Activities of daily living (ADLs) – bathing, dressing,

eating, transferring, toileting

– Instrumental activities of daily living (IADLs) – cooking, meal preparation, house cleaning, handling finances, laundry, using phone, shopping, taking medication

– Driving history

– Work/volunteer/travel – exercise

– Assistive devices – gait/mobility issues


Older Age Examination (cont’d)

– Fall history• If functioning, have 15-35% risk of death within

the first year following the fall• 33% end up in nursing home with only 33% of

them regaining pre-fracture functional status• Recurrent falls is defined as > 2 falls in a

six-month period of time

– Delayed Word Recall (DWR)

– Clock/pentagon


MMSE

• Mini-Mental State Examination (MMSE): – 30-point standardized questions evaluating:

• Orientation• Concentration• Verbal skills• Visual-spatial skills

– Easy to perform– Portable– Can be done by primary medical doctor,

paramedical vendor


MMSE (cont’d)

• MMSE scoring system

MMSE Score Range (0-30)

24-30 No impairment

18-23 Mild impairment

0-17 Moderate to severe impairment


MMSE (cont’d)

Orientation What is the (year) (season) (date) (day) (month)? 5 Where are we: (country) (city) (part of city) (number of flat/house) (name of street)? 5

Registration Name three objects: one second to say each.Then ask the patient to name all three after you have said them.Give one point for each correct answer.Then repeat them until he learns all three.Count trials and record. 3

TRIALSAttention and calculation

Serial 7s: one point for each correct.Stop after five answers.

5Recall

Ask for the three objects repeated above.Give one point for each correct. 3

Language Name a pencil and watch (two points).Repeat the following: 'No ifs, ands or buts' (one point).Follow a three-stage command: 'Take a paper in your right hand, fold it in half and put it on the floor' (three points).Read and obey the following: Close your eyes (one point).Write a sentence (one point).Copy a design (one point).9

» Total Score_


MMSE & Level of Education

Age Education Score

18-69 High School 28-29

College 29

70-79 High School 27-28

College 28

80+ High School 25-26

College 27


Memory Loss, Alzheimer’s Disease & Vascular Dementia

• NOT a part of normal aging• Risk of developing disease increases with age – severity

increases with age• Defined as cognitive impairment

– to include memory impairment as well as at least one of the following: aphasia, apraxia, agnosia, executive function disturbance

– impaired social or occupational functioning– gradual onset/continuing decline– other causes ruled out

• National Institute of Aging – for every five-year age group beyond 65, the percentage of people with symptoms doubles


Medications for Dementia

• Commonly seen medications used to halt the progression of dementia include:– Cognex (tacrine)– Aricept (donepezil)– Namenda (memantine)– Exelon (rivastigimine)– Razadyne (Reminyl) (galantamine)


Clock Test


Pulmonary Function Test

• Pulmonary function, as measured by forced expiratory volume in one second (FEV1) or forced vital capacity (FVC) are important independent predictors of morbidity and mortality in the elderly

• Lung function declines slowly throughout adult life, even in healthy individuals


Serum Albumin

• Serum albumin level is an independent risk factor for all-cause mortality in older persons

• A combined measure of albumin and disability reveals a strong gradient in mortality risk and may serve as a simple but useful index of frailty that can identify a high-risk group of older men and women who could be targeted for preventive and treatment efforts

Source: JAMA: The Journal Of The American Medical Association, Vol. 272, No. 13, October 5, 1994.


Serum Albumin (cont’d)

• Serum Albumin– Normal = 3.6 g/dL – 4.9 g/dL (prefer >4.2 g/dL)

– Abnormal = <3.6 g/dL

**concerned when <3.8 g/dL with loss of more than 10% body weight within the last six months


Kidney Function & Cardiovascular Disease

• Long-term adverse outcomes associated with chronic kidney disease include kidney failure, complications of impaired kidney function, and more commonly, an increased risk for cardiovascular disease and death– Annual mortality from CVD is increased 10-100

times with kidney failure– Risk of CVD is increased 1.4-2.05 times with

creatinine > 1.4-1.5 mg/dL– Risk of CVD is increased 1.5-3.5 times with

microalbuminuria


Glomerular Filtration Rate – eGFR

• eGFR is equal to the sum of the filtration rates in all the functioning nephrons – how well kidneys are filtering wastes

• Normal value of eGFR depends on age, sex, body size

• Not an exact correlation between loss of kidney mass and loss of kidney function


Clinical Implications – eGFR

• eGFR is used to assess degree of kidney impairment and to follow the course of the disease

• Using serum creatinine alone to estimate eGFR is unsatisfactory and leads to delays in diagnosis & treatment of CKD (chronic kidney disease)

• Elevation in serum creatinine does not always occur until there has been approximately a 50% loss of kidney function


Serum Creatinine

• Mean serum creatinine:– Women: 0.93 mg/dL– Men: 1.13 mg/dL

• Varies by race

• Value lower in women due to less muscle mass and therefore less production of creatinine

• Increased weight = increased creatinine production

• With age, there is a decline in creatinine production (muscle mass decreases with age)

• Declines by approximately 1mL/min per 1.73m2 per year after 40 years of age

• Increasing age is NOT invariably associated with an abnormal eGFR


Stages of Chronic Kidney Disease

Stage Description GFR Level

Normal kidney function

Healthy kidneys 90 mL/min or more

Stage 1 Kidney damage with normal or high GFR

90 mL/min or more

Stage 2 Kidney damage and mild decrease in GFR

60 to 89 mL/min

Stage 3 Moderate decrease in GFR 30 to 59 mL/min

Stage 4 Severe decrease in GFR 15 to 29 mL/min

Stage 5 Kidney failure Less than 15 mL/min or on dialysis

Source: National Kidney Foundation


Conclusions


Underwriting Tools Review

• Cover letter

• John Hancock exam includes:– Details of medical questions– Exam findings– Older age section

• Word recall and orientation• Mobility test• Functionality

– Blood and urinalysis results

• APS information– Remember dual residence– Dual medical care


Putting It Together

Are these older age applicants insurable?


Putting It Together (cont’d)

• YES!!!! Older age applicants are insurable!!

• Stay informed, be prepared to ask for more details if necessary with a focus on VEDS: Vitality, Energy, Dexterity and physical Strength

• Some mortality risks at younger ages taper off with advancing age

• Risk of co-morbidities – and how it impacts VEDS


The Challenge

• Putting it all together:

– Look at all the information

– Identify favorables and unfavorables

– How do the co-morbidities fit together?

– How do any functional capabilities or limitations factor into assessment?


Underwriting Tips

• Underwriting the older age applicant is an “art”• Look at the picture displayed by the information carefully• Those that present favorable VEDS are best risks


Questions?

For Agent Use Only. Not for Use with the Public. Underwriting the Elderly Cas Pengelley General...

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