Assessing the risk of cognitive disorders

prepare meals use transportation grocery shop clean house do laundry do laundry clean house grocery shop use transportation prepare meals use the telephone manage medications IADL functions tend to be complex, requiring a combination of physical and cognitive capacities. For example, shopping requires mobility and a relatively intact cognition to handle the financial transactions involved. […]

By Hélène Michaud, Joan Tolan | December 21, 2009 | Last updated on December 21, 2009
6 min read
  • prepare meals
  • use the telephone
  • manage medications

    IADL functions tend to be complex, requiring a combination of physical and cognitive capacities. For example, shopping requires mobility and a relatively intact cognition to handle the financial transactions involved. Loss of IADLs is, in some ways, a precursor to future loss of ADLs.

    The ability to perform certain IADLs may be gender-related, in that women have traditionally performed some of the activities, while men have more commonly performed others. What matters is not only whether a person currently performs an activity, but also whether they are capable of performing it if required to do so for an extended period of time — without assistance.

    The interview process

    Personal history interviews (PHIs) usually over the phone are being used for younger applicants while face-to-face interviews (FTFs) are conducted on older applicants (ages 70 – 72+).

    General information questions are asked to provide a basic understanding of the applicant including employment, hobbies, activities and living arrangements. Medical questions are also used to both confirm application details and elicit additional information on medical history. The applicant will be asked to provide a list of all prescriptions and over-the-counter medications taken and describe any medical equipment being used. With FTFs, the assessor may also record the applicant’s height, weight and blood pressure. The applicant is also asked to participate in a cognitive exercise — such as the EMST to determine if there is any underlying impairment that will affect future memory function.

    The remainder of the assessment relates to questions about performing daily activities (ADLs and IADLs). At the end of the interview, the applicant will be asked to sign and date the face-to-face interview form. The assessor will ask to see a form of picture identification, such as a driver’s license or passport to verify the signature. Along with the interview, medical records obtained from attending physicians complete the risk assessment process.

    These underwriting tools can actually allow the underwriter to approve cases. For instance when you think of stroke you automatically think of someone who has paralysis and is bedridden. Yet a home visit or PHI will gather details that allow us to approve as the client may be back to their daily activities – which would not necessarily be reflected in the medical records.

    Industry practices

    Insurers are routinely using telephone and in person assessments as part of the LTC evaluation. Cognitive screening, with tools such as the EMST, is an important part of a comprehensive review to ensure long term product success.

    Case Study A

    On March 22, 2008, a 71-year-old male applied for a $3,000/month, three-year benefit duration, 90-day elimination period home care and facility care policy.

    His application denied any medication use and stated that his last doctor’s visit occurred earlier in the month for a sore shoulder. The agent described him as active and independent A telephone interview revealed the applicant remained medication-free and that the strained shoulder was treated with exercise. He reported being independent and he passed the cognitive portion of the interview. The medical records confirmed his shoulder self report and also indicated a history of prostate cancer with no metastasis in 2005 and degenerative arthritis in his right knee with no limitations. His application was approved.

    Case Study B

    On March 11, 2008, a 77-year-old female applied for $1,500/month, lifetime benefit duration, 30-day elimination period comprehensive policy.

    Her application indicated a history of hypertension treated with Hyzaar and Tiazac, as well as an episode of shortness of breath in May. No details were supplied for this episode or the diagnosis. Her last doctor’s visit occurred in February 2008 for a routine examination.

    During an in-person interview, she reported that her hypertension has been controlled since 1990. Along with the medications noted on her application, she also revealed taking medications for her stomach, cholesterol and breathing in addition to dietary supplements. She also admitted history of forgetfulness for which she consulted her doctor but did not recall the complete details of the conversation. The assessor noted she was distracted, had wandering thoughts and it was difficult keeping her focused throughout the interview. She did not pass the cognitive exercise.

    Medical records were cancelled because she was uninsurable based on cognitive results and reports of forgetfulness/memory loss. Her application was declined.

  • Joan Tolan is the vice-president, Underwriting Canada & Underwriting Best practices, North America, with special contribution from LifePlans LTC Services, Inc. at Munich Re.

    Hélène Michaud, Joan Tolan

  • use transportation
  • prepare meals
  • use the telephone
  • manage medications

    IADL functions tend to be complex, requiring a combination of physical and cognitive capacities. For example, shopping requires mobility and a relatively intact cognition to handle the financial transactions involved. Loss of IADLs is, in some ways, a precursor to future loss of ADLs.

    The ability to perform certain IADLs may be gender-related, in that women have traditionally performed some of the activities, while men have more commonly performed others. What matters is not only whether a person currently performs an activity, but also whether they are capable of performing it if required to do so for an extended period of time — without assistance.

    The interview process

    Personal history interviews (PHIs) usually over the phone are being used for younger applicants while face-to-face interviews (FTFs) are conducted on older applicants (ages 70 – 72+).

    General information questions are asked to provide a basic understanding of the applicant including employment, hobbies, activities and living arrangements. Medical questions are also used to both confirm application details and elicit additional information on medical history. The applicant will be asked to provide a list of all prescriptions and over-the-counter medications taken and describe any medical equipment being used. With FTFs, the assessor may also record the applicant’s height, weight and blood pressure. The applicant is also asked to participate in a cognitive exercise — such as the EMST to determine if there is any underlying impairment that will affect future memory function.

    The remainder of the assessment relates to questions about performing daily activities (ADLs and IADLs). At the end of the interview, the applicant will be asked to sign and date the face-to-face interview form. The assessor will ask to see a form of picture identification, such as a driver’s license or passport to verify the signature. Along with the interview, medical records obtained from attending physicians complete the risk assessment process.

    These underwriting tools can actually allow the underwriter to approve cases. For instance when you think of stroke you automatically think of someone who has paralysis and is bedridden. Yet a home visit or PHI will gather details that allow us to approve as the client may be back to their daily activities – which would not necessarily be reflected in the medical records.

    Industry practices

    Insurers are routinely using telephone and in person assessments as part of the LTC evaluation. Cognitive screening, with tools such as the EMST, is an important part of a comprehensive review to ensure long term product success.

    Case Study A

    On March 22, 2008, a 71-year-old male applied for a $3,000/month, three-year benefit duration, 90-day elimination period home care and facility care policy.

    His application denied any medication use and stated that his last doctor’s visit occurred earlier in the month for a sore shoulder. The agent described him as active and independent A telephone interview revealed the applicant remained medication-free and that the strained shoulder was treated with exercise. He reported being independent and he passed the cognitive portion of the interview. The medical records confirmed his shoulder self report and also indicated a history of prostate cancer with no metastasis in 2005 and degenerative arthritis in his right knee with no limitations. His application was approved.

    Case Study B

    On March 11, 2008, a 77-year-old female applied for $1,500/month, lifetime benefit duration, 30-day elimination period comprehensive policy.

    Her application indicated a history of hypertension treated with Hyzaar and Tiazac, as well as an episode of shortness of breath in May. No details were supplied for this episode or the diagnosis. Her last doctor’s visit occurred in February 2008 for a routine examination.

    During an in-person interview, she reported that her hypertension has been controlled since 1990. Along with the medications noted on her application, she also revealed taking medications for her stomach, cholesterol and breathing in addition to dietary supplements. She also admitted history of forgetfulness for which she consulted her doctor but did not recall the complete details of the conversation. The assessor noted she was distracted, had wandering thoughts and it was difficult keeping her focused throughout the interview. She did not pass the cognitive exercise.

    Medical records were cancelled because she was uninsurable based on cognitive results and reports of forgetfulness/memory loss. Her application was declined.

  • Joan Tolan is the vice-president, Underwriting Canada & Underwriting Best practices, North America, with special contribution from LifePlans LTC Services, Inc. at Munich Re.