Chapter 5- Underwriting The Elderly Flashcards
What is the average life expectancy of a human being from birth (polled in 2010)?
Who lives longer; men or women?
78.7 years
Females > Males by 5 years.
What are 3 unique qualities of the elderly population?
- heterogenity of the population
- presence of comorbid conditions
- occurrence of frailty
Define Population heterogeneity
diversity in health status among individuals of similar age.
-expressed on an individual bais in that the signs and sxs of a disease can be unusual and the impact on pts can vary as such
Define comorbidity
the combination of two or more impairments that increase the risk of morbidity and mortality.
- Females have more co-morbid conditions, placing them at higher risk for functional impairments.
define frailty
geriatric syndrome characterized by a high risk for a variety of poor outcomes that include: dependency, institutionalization, falls, injuries, acute illness, hospitalization, slow recovery from illness and death.
- prevalence rises steply with age, (56.3% of 90 yo’s)
Tue or False
The average group risk of the elder population hold true from the group risk of the whole population.
False, elder is not a STD average riskl
Do lapse rates increase or decrease with age increase
Decrease
What is the primary cause of accidental mortality?
Falls, 70%
What are driving risks associated with the elderly population
visual acuity, hearing loss, medication usage, medical impairments, cognitive decline and reduced reflexes = decreased motor safety
What are the most common moving violations among the elders?
failure to yield at right of way
failure to obey a traffic sign/light
fatalities increase 15% >65 yo.
collisions caused by elderlies are likely to be multi-vehible.
True or False characteristics of diseases can change based on age. Give an example
True,
CP indication of MI in young people, but >30% of MI go undetected in elderly d/t lack of sxs.
define polypharmacy
the concurrent use of multiple medications
=> increases risk fo drug toxicity.
What is drug toxicity?
toxicity caused by improper dosing, drug/drug interactions, and non-compliance.
What are 4 major causes of morbidity in the elderly?
- arthritis
- hypertension
- hearing impairments.
- heart disease.
does the tx of CAD alter between age groups?
no but the outcomes differ d/t the extent of the disease and the presence of co-morbid conditions.
What tx is helpful in reducing sxs of CAD, but becomes more risky for the elderly?
PTCA - used for less extensive disease, stable angina, and less co-morbids.
CABG- in older individuals have a better survival numbers than younger individuals
What is the most common significant valvular disease in older individuals?
Calcific aortic stenosis
what is the 5- year survival percentage of those who have symptomatic aortic stenosis who are medically treated?
50%
Is using physical examination for aortic stenosis as precise in older and younger individuals?
No- less so in elderly
Intensity of the murmur is not indicative of the severity of the obstruction.
ECHO is better
Which type of valvualr heart disease is more common in the elderly population?
mitral and aortic valve disease.
Calcific aoritc stensois is the most common siginficant valve disease.
when evaluating risk of valve diseases, what can an UW look for in terms of testing?
decreased exercise tolerance
increasing dyspnea
When is valve replacement suggested?
presence of aortic stenosis or aortic insufficiency.
prognosis is worse with insufficiency hx, and its the most common.
What is the typical cause of mitral stenosis in the elderly population?
hx of rheumatic fever
- many people stay Asxs.
- can develop into LAH which developes into in a fib.
True or False
prognosis for elderly with murmurs w/o complications is similar to younger generations?
True
What are some factors affecting Left ventricular compliance?
- degree of wall thickness, which naturally increases with age.
- its measured by doppler echo E/A ratio.
What are the compoenents to EA ratio?
E = early filling phase of Lt ventricle during diastole. Depends on muscle relaxation. A= atrial contraction that occurs during late diastole, ie; pressure to complete diastolic filling of the Lt ventricle.
Healthy E/A ration >1
delay reaction = E/A <1
Elderly individuals: psydonormalization is where E/A >1
What do you call the extreme form of ventricular noncompliance that is frequently seen in elderly women with longstanding HTN?
diastolic failure
What lifestyle change has a great affect on arterial pressure control?
low salt diet
^ exercise
What is the second leading cause of death among the elderly?
Cancer
Most cancers have a similar prognosis for both young and old populations. What types of Cancer have a better prognosis for the elderly population?
What types of Cancer have a worse prognosis for the elderly population?
Better:
stage 0 chronic lymphocytic leukaemia
breast-cancer
prostate- cancer
Worse:
thyroid cancer
Hodgkins disease.
Is the prognosis for elderly people with IBD worse or better when compared to younger people?
worse
co-morbids can add complications
usually goes undx’ed or is dx’ed too late
What are the most common fractures in the elderly population?
vertebrae
wrist
hip > greatest mortality d/t complications including pneumonia, MI and Stroke, thrombosis
What is the period of greatest mortality following a hip fracture
6-12 month period 700% risk of complication.»_space; PE is a leading fatal cause
Deine osteoporosis
defined as Bone Mineral Density (BMD) measured by dual-energy x-ray absorptiometry (DEXA) of 2.5 std deviations below young adult.
F more at risk following post-menopausal period, males at risk >50 yo.
Define Proteinuria
associated with renal and non-renal diseases.
presence of microalbumin in the urine which is a predicament for vascular disease, HTN, kidney disease.
- more prevalent in the elderly and associated with excess mortality from CV and renal causes. p
- prognosis the same in both groups
What are the risk factors that have been identified by the Framingham Heart Study?
- Smoking
- HTN / LVH
- Cholesterol
- Build
- Diabetes
- Family history
Why is smoking less common among the elderly?
increased PR about hazards of SM
medical problems prevent them from smoking
A lot of SM generation died.
Smoking is a major risk factor for what diseases?
stroke cancer emphysema Chronic bronchitis other cause of death
risk of developing HTN increases with Age. Why?
vascular distensibility and elastic recoil of arteries diminish
increases in peripheral resistance of the blood vessels
secondary causes develop: kidney and artery disorders.
- Young/old affected the same.
- controlled/ tx’ed HTN = better prognosis.
What are the two patterns of HTN?
- isolated systolic hypertension > independant mortality risk.
- combined systolic/diastolic hypertension.
What is the mortality risk of Hypotension?
Mortality curve is U or J shaped.
theory for why morality increases:
1. Low BP does not allow blood to perfuse vital tissues in individuals with atheroscletortic disease
2. Low blood pressure in previously hypertensive patients can be a marker of poor health resulting from another underlying disease.
- Those with hypotension w/o a prior HTN hx are good risks.
How can you lower the risk of CAD in terms of lipid control?
- Statins (lipid reducing tx)
2. diet
Is low cholesterol good for the elderly?
There is an increase in mortality risk with low serum cholesterol.
U or J shaped mortality table.
A decline in cholesterol is a red Flag for possible cancer
What are the risks associated to underweight elderly?
cancers
Cerebrovascular events
pneumonie
** unexplained weight-loss can be associated to underlying condition
Is the CAD risk of an increase build the same amount both age groups?
No, the risk decreases with elevated BMI over the age of 60.
- some benefits to excess body weight to protect from falls, and supplies nutritional reserves during illness
Does the risk of developing CAD with a history of diabetes increase or decrease as you age?
DM more prevalent in older ages.
mortality ratios decreased as NIDDM pt’s get older.
What is the CAD risk when reviewing Fx?
CAD risk increase with Fx of CAD diagnosed prior to age 60.
What is included in the assessment of functional status?
consideration of physical, social, and cognitive areas.
How can an UW review the functional status of the elderly? What do you look for? [ASCENT]
A- ADLs, IADLs, AADLs S- social involvement C- cognition E- exercise capacity N- nutrition T- trips/falls/.
Define
- ADLS [activities of daily living]
- IADLS [instrumental activities of daily living]
- AADLS [Advanced activities of daily living]
- functions that must be performed to live independently and to provide selfcare
- tasks that allow the individual to funtion independently in the community
- activites that add meaning and richness.
What are the Basic activities of Daily living? (6)
- bathing
- dressing
- toileting
- transferring from the bed to chair
- eating
- urinary and bowel continence.
What are the 7 IADLS?
- telephoning
- handling personal finances
- using transportation services
- shopping
- meal preperation
- House work
- taking medication
What are the examples of AADLs?
- working
- attending church
- going out to dinner, theater, movie, concert
- participating in recreational activities
- driving
- playing cards
What are some risks associated to impaired social livings?
isolation increases risk of depression and suicide.
suicide more common in white males >85. increased suicide risk with alcohol abuse.
Are bereavement periods worst or better in the elder population?
worst -
6-12 months recovery is typical.
What are some examples of prolonged or unresolved grief?
- poor-self rated health
- agitated depression
- feeling of worthlessness
- lack of desire to perform self-care functions such as grooming or cooking
- frequent physician visits.
Cognitive disorders can include impairements in what?
- short and long-term memory
- orientation as to person, place, time
- deductive or abstract reasoning
What is the definition of dementia?
global impairment of cognitive function and affects 13.9% of the individuals age 71 and older.
What is the most common type of dementia?
Alzheimer’s type (DAT)
progresses over a period of time [2-30 yrs]
Alzheimers starts with short-term memory impairment, mild memory loss, then functional disability, wandering, falls, malnutrition, immobility and death. What are some factors associate with the length of survival?
- severity
- occurrence of wandering and falling
- hearing loss
- age at onset of sxs
- behavioural problems.
What do you call the muti-infarct dementia?
vascular dementia (VaD) caused by multiple strokes.
What medical history can lead to an increase in the risk of having multiple cerebral infarctions?
- HTN
- Diabetes
- CAD
- Hypercholesterolemia
- Cerebrovascular disease.
Some other dementias are partially or totally reversible, most have an underlying cause that can be tx’ed. Name the causes of reversible dementias
- drug use
- emotional disorders and depression
- metabolic and endocrine disorders
- eye and ear impairements
- nutritional deficiences
- tumors
- trauma
- infection
- Some atherosclerotic complications.
How is dementia diagnosed?
history + physical examination
neurological exam
mental status exam
lab testing for (reversible dementia)
What is the most commonly used mental status exam?
Folstein Mini-Mental state Exam (MMSE)
- memory and cognition
- scores lower than 24 out of 30 suggest dementia or severe depression
What tools can be used to assess cognition?
- MMSE
- Clock drawing test
- Delayed work recall
- Minnesota Cognitive Acuity Screen (MCAS)
- Blessed Dementia Scale (BDS)
What other disorders can the MCAS detect?
by testing memory and complex thinking, they can detect mild/moderate dementia. and non-Alz syndromes: vascular dementia, lewy body dementia, Korsikoff dementia.
What imaging is used in the diagnosis process of dementia?
CT and MRI- depending on suspected cause. MRI is more sensitive.
PET and SPECT can be used, but they’re not great/.
Presence of White Matter lesions is a marker for what disease?
Vascular,
also links to future risk of dementia.
How are exercise levels measured?
Stress test- using the amount of oxygen that is consumed and used by the body per KG of body weight per min.
at rest MET is equal to 3.5, basic activities of living require 5 METS. >9 METS = reduction in all-cause mortality.
Cycle ergometer- measured in KPDs. 10 METs = 1050 KPDS.
What is chronotropic incompetence?
inadequate HR response to exercise
> predicts mortality in multivariate analyses.
UW can analyze exercise capacity using the Goldman Specific Function Activity Scale ( GSFAS) what is this?
5 question test asking about the ability to perform certain physical activities:
1. walking down flight of steps without stopping
2. carrying an object up a flight of 8 steps without stopping
3. Carrying 24 lbs up 8 steps without stopping
4. showering, dressing without stopping.
Answers are compared to NYHA and Canadian Cardiovascular Society.
What are some causes of Low serum Albumin levels?
long-term protein and energy deprivation liver and renal disease acute and chronic illnesses, inflammation, trauma poor physical function
What is the mortality risk increase of people >65 yo, who fell in therehomes?
4x higher than people who had not fallen.
if on the floor >1 hour risk increased to 7.6 fold.
What are 15 factors that increase the risk of falling?
- inability to extend the back
- moderate limitation in cervical range of motion
- decreased lower extremity strength
- self-percieved mobility problems
- use of a walking aid
- poor turning balance
- shuffling gait
- decreased knee strength
- difficulty rising from a chair
- poor immediate standing balance 5 seconds after standing
- decreased distant vision
- orthostatic hypotension
- any lower extremity incoordination
- needing help with two or more ADLs
- poor balance upon sitting down.
What are typical lab abnormalities in the aging population
- A1C - typical slight elevations, higher ones = diabetes, leads to proteinuria
- BUN/CR - sig elevations usually indication for renal impairments.
- Albumin/Globulin : low levels associated to liver/kidney/U.C./ inflammatory disease.
- Alk phosphate: ^ related to osteomalacia, liver disease, pagets, disease and bone malignancies.
- lipids: slightly increase is normally and plateaus at 65.
- Brain natriuretic peptide (BNP_ and (NT-proBNP) used for dx and tx of heart failure.
What are the typical evidence requiremetns for UW the elderly
- geriatric assessment with cognitive and functional capabilities
- current, physical examination and urinalysis
- copy of complete APS
- exercise ECG
- Blood work, CBC
- pulmonary function test
- CXR
- tele-interview
- MVR
- RX check.
What are some suggested additions to the examination section for elderly applications?
- Orthostatic BP reading (3 mins standing)
- questions about insureds ability to ambulate with possible tests such as timed up and go test (TUG)
- questions about cognitive ability
- attempt to detect depression
- The place the examination was completed recorded on the form
- A note by the examiner if blood was done and what Rx has been taken in last 10 days.
Which part of the Spirometry was the most highly correlated with cardiovascular mortality?
the FVC- forced vital capacity.
Females have lower levels than males, and on average decline as age increase.
Rate of decline increases with SM hx.
FEV1 is also used
What are the 6 factors of an ideal elderly applicant? (favourable factors)
- mentally competent - no memory issues
- lives independently
- performs all IADLS
- has an APS from whom records of regular visits are available
- has no hx of stroke, heart attack, , surgery, or sig recent disability
- is socially active outside the home.
What are some examples of pour medical history factors?
- more than two CAD surgeries
- any sign of CAD since surgery
- compromised mental capacity
- sig, unexplained weight loss in the last year
- demonstrated an inability to perform one or more basic ADLs .
- no physician.
What are commonly used parameters to develop preferred criteria in the odler-age groups?
- functional and cognitive capacity
- exercise capacity
- blood pressure
- build
- serum albumin and serum creatinine
- cholesterol
- Personal hx of disease
- driving record
- hx of substance abuse
- aviation and hazardous sports.
What are 3 riders that focuses on elderly individuals.
- CI rider
- chronic illness rider
- Long-term Care Rider.
what are two possible criteria that can be met to qualify for a chronically ill diagnosis?>
- unable to perform without substantial assistance from another individual, 2 of 6 ADLS- due to a loss of functional capacity
- possesses a sever cognitive impairment requiring substantial supervision to protect the insured from threats to health and safety
