Clinical Aspects of Long-Term Risk Management

6. Identifying Frailty at Underwriting

The principle risk factors for frailty and hence functional decline are outlined in Table 1.

Table 1: Principle risk factors for frailty

The risk factors for frailty demonstrate how the of the bio-psycho-social model works. Biological features (age, co-morbidity, polypharmacy) rub shoulders with psychological functions such as cognition and social factors (social isolation, income and education) to contribute to the degree of frailty.

7. The Application Form

The information needed to assess frailty is not available on standard insurance application forms, and specially designed data collection forms are required. In addition to many of the standard questions, specific information on IADLs is sought (Table 2). Failing of IADLs predicts future failure of ADLs (e.g., Peres et al., 2006). The forms must capture change in IADLs as well as the current state of functioning. The forms must also explore the social aspects of a person’s life (e.g., hobbies and pastimes).

Table 2: Instrumental activities of daily living


8. Paramedic Examination

The traditional paramedic examination is extended in LTC underwriting. The paramedic must ask more in depth questions about ADL and IADL functioning Exploring the changes in functioning over time is a vital part of examination (Has this changed in the last year?). Knowing more about hobbies and pasttimes is important. A daily walk to and from the bar on the corner of the street is very different from a couple of miles across the fields with the dog. An interest in gardening can mean anything from looking at the garden through the window to regular digging sessions in the vegetable patch. The para-medic is also able to see the person in their own home and get a much better idea about how they are coping day to day. This kind of information is unlikely to be available from any other source.
A vital part of the paramedic examination is the examination of the cognitive state.
There is no test that captures all then attributes of an ideal test (Table 3).

Table 3: Attributes of the ideal cognitive screening test


A number of candidates (e.g., Mini-Mental State Examination (Folstein, Folstein and McHugh, 1975) are available, but whichever test is chosen, there are a number of important issues:
1.    Paramedics must be trained to undertake the test in a standardised manner.
2.    The scoring algorithms must be consistent.
3.    The interpretation of the test by the underwriters must take into account the person being tested. Where LTC insurance is expensive it is sold to well-educated middle class individuals who are motivated to do well in the tests. Small decrements in these tests are likely to be more significant than when these tests are part of epidemiological surveys.
The longest and most expensive claims are those arising from cognitive failure. Identification of the ‘pre-dementia’ states with their different definitions (e.g., Mild Cognitive Impairment, Questionable Dementia, etc.) is important, as the there is a significant progression to dementia each year Table 4.

Table 4: Conversion rates to Alzheimer’s disease of ‘pre-dementia’ conditions


Source: After Petersen et al. 2001.

9. General Practitioners Reports

General Practitioner Reports (GPRs) are good for getting lists of diagnoses and medication. They will also be able to furnish information about the control of medical symptoms over time (e.g., blood pressure or blood sugar). Where they are less useful is in their information about the functional status of the applicant and in recognising cognitive impairment. Up to 65% of those with dementia are not recognised as suffering from the disease by their GP. This is particularly problematic for those with mild dementia where 80% might go unrecognised (Illife et al., 2000).

10. Conclusion

Restructuring the information collecting process brings to the underwriters desk information that allows sophisticated assessment of risk. The information must be understood within paradigms of LTC risk and not in the more traditional life health underwriting structures (Table 5).

Table 5: Risk paradigms in young and old


Source: After Ashley, 2004.

Merely taking each diagnosis and applying a rating ‘silo underwriting’ is likely to underestimate risk. The development of the Gen Re Long-Term Care manual seeks to challenge this approach by offering the underwriter grids for the major diseases which allow ratings for different severities of the disease based on both biological and functional severity. The clinical approach to the assessment and management of health problems in the elderly has been a significant influence on the development of this approach to risk management.


Ashley, T. (2004): “GREAT Risk Assessment in the Elderly”, Risk Insights 8, pp. 1-5.

Folstein, M.F, Folstein, S.E, McHugh, P.R. (1975): “Mini-Mental State”: A Practical Method for Grading the Cognitive State of Patients for the Clinician, Journal of Psychiatric Research, 12: pp. 189-98.

Illiffe, S., Walters, K. and Rait, G. (2000): “Shortcomings in the Diagnosis and Management of Dementia in Primary Care: Towards an Educational Strategy”, Aging & Mental Health, 4, pp. 286 – 291.

Klein, B.E.K., Klein, R., Knudtson, M.D. and Lee, K.E. (2005): Frailty, Morbidity and Survival, Archives of Gerontology and Geriatrics, Volume 41, pp. 141-149.

Markle-Reid, M. and Browne, G. (2003): “Conceptualizations of Frailty in Relation to Older Adults”, Journal of Advanced Nursing, 44, pp. 58-68.

Pérès, K., Chrysostome, V. Fabrigoule, C. et al. (2006): “Restriction in Complex Activities of Daily Living in MCI”, Impact on outcome, Neurology, 67, pp. 461-466.

Petersen, R.C., Doody, R., Kurz, A. et al. (2001): “Current Concepts in Mild Cognitive Impairment”, Archives of Neurology, 58, pp. 1985-1992.

Rickayzen, B.D. and Walsh, D. (2002): “A Multi-State Model of Disability for the UK: Implications for Need for Long Term Care for the Elderly”, British Actuarial Journal, 8. pp. 341-393.

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