Challenging Myths and Rethinking Priorities in Older Age Underwriting: An Essay
To determine insurability of applicants age 65 and over on the same basis as we do at younger ages all but guarantees a botched job.
This is because factors that we know contribute to premature death in young and middle-aged adults differ dramatically from those linked to excess geriatric mortality. These examples give clear evidence of this too-often-overlooked reality.
At younger ages, vitality is a given. Not so in the “golden years,” where the capacity to “merely” carry off routine activities of daily living (ADLs and companion IADLs) has been shown to be a more imposing predictor of survival than diabetes.
If discussions at my life underwriting study groups reflect industry reality, then only a handful of life companies employ a long-term-care version of the paramedical exam designed to probe physical capacity.
A number of studies have shown that current tobacco indulgence in the seventh decade and behind translates to very modest extra risk in males and none whatsoever in females. To overemphasize this risk-taking behavior at the expense of other considerations is to mistake the sapling for the forest.
The emphasis should rightly be on PACK YEARS, not current smoking. And we can derive PACKL YEAR data during the routine TELEINTERVIEW.
While definite hypertension impacts longevity at all ages, the reality is that its mortality slope becomes distinctly U-shaped late in life. When systolic and/or diastolic readings are too low, the implications are more ominous than when they fall into modestly debited ranges.
It is a frank shame that we do not yet recognize the sinister nature of high “pulse pressure” (the difference between the systolic and diastolic readings) for what it really means.
Such a facile calculation.
Such a potential asset to determining the real risk implications of not only hypertension but “normal” readings as well.
At younger ages, lower is better. Not so later on, when a low or, worse, falling cholesterol (in those not on lipid-lowering Rx, of course) is a proven harbinger of early demise.
It is time to assign debits – on not minimal ones, to be sure – in situations where the current cholesterol is low (<140 mg/dL) in the absence of Rx. If it is falling from a previous high level, the risk is worse. If the serum albumin is low, the risk is multiplicative at best. Ditto for an HDL < 30 mg/dL.
And if the total cholesterol is extremely low (< 100 mg/dL), accompanied by very low triglycerides and very low HDL-C, this raises the specter of cirrhosis. Take another look at ALL the liver-related tests – and don’t be dissuaded from pursing the issue if the aminotransferases (ALT, AST) happen to be normal or minimally elevated.
Abuse of alcohol is worrisome at all ages. However, three distinct realities must be born in mind when assessing its impact over age 65:
- First, the elderly are far less tolerant of alcohol’s acute effects, so that what we consider “social drinking” at age 40 confers genuine risk three decades later.
- A second consideration is the synergy of alcohol intake and medication effects.
- Two beers and the wrong pill – which may have been correctly prescribed for the right reason – can beget the fall that begets the hip fracture that begets fearsome short-duration mortality.
- Lastly, our elders are quite adept at “hiding the bottle!” Woe betides he who discounts even equivocal laboratory and medical history clues to overindulgence in the geriatric risk population.
One of the most disturbing deviations from good underwriting is our rampant failure to appreciate the implications of diabetes at all ages. It is axiomatic in studies of virtually all impairments that the diabetic will fare far worse than those with normal glucose metabolism. This becomes proportionally more important over age 65, as the incidence of diabetes rises and some other prominent cardiovascular risk factors lose much of their impact.
In this underwriter’s view, the pretense of the “preferred diabetic” is one of our most ill-conceived oxymorons!
The mortality of “build” is distinctly U-shaped at older ages. So much so that one could make a convincing argument for underweight being the real issue. Nevertheless, we continue to measure this risk solely in terms of weight in relation to height. A two-inch-thick stack of research studies proves that it isn’t “how much you carry” but “where you carry it” that makes all the difference. How many well-heeled, pleasingly plump elderly ladies are unwitting victims of our failure make use of the waist-to-hip ratios, the best benchmark where obesity is concerned.
This underwriter remains flummoxed by the assertion by some that waist-to-hip ratios cannot be measured during routine paramedicals. Think of the value they might add in the aforementioned scenario!
Older people take more medications than their offspring. Indeed, this phenomenon has earned the label “polypharmacy.” In some cases – use of benzodiazepine sedatives like Valium® being a clear example – the implications of drug effects may translate to risks all too often unappreciated.
These are just a few examples of how older age underwriting is more distinctive than many prevailing underwriting practices recognize.
Has the time come for this knowledge to be translated into new geriatric risk paradigms?
Is the PREFERRED geriatric risk distinctly different from the PREFERRED applicant in midlife (and that individual, in turn, distinctly different from the 18-39 year old)?
Do we not, in fact, have three distinctive subsets of PREFERRED?
This underwriter does not hesitate to offer up his emphatic YES to these questions.