Sleep disorders affect many people in the UK. John Haseman explains how this impacts on the underwriting process
Insomnia is usually one of the first thoughts to spring to mind when considering sleep disorders. The condition, which is the inability to, or the disruption of, sleep is frequently linked to an underlying mental disturbance such as anxiety or depression. However, insomnia is only one of many sleep disorders, which are more common and can be more serious than many people think.
Essentially, sleep disorders can be grouped into two broad categories, primary and secondary. Primary sleep disorders can be split according to disturbance in the amount, quality or timing of sleep - dysomnias, and unusual behaviour during sleeping - parasomnias. Dysomnias are more prevalent with increasing age whereas parasomnias are more prevalent in childhood.
Recurrent episodes
One primary disorder receiving more and more exposure is narcolepsy. This can have a profound effect on the underwriting of an insurance application. Narcolepsy is when a person suddenly falls asleep. It is a neurological sleep disorder first identified in 1880 by Jean-Baptiste Gelineau and has no known cure. It is characterised by uncontrollable, recurrent episodes of daytime sleep lasting from 15 minutes to an hour. Signs usually begin between the ages of 15 and 30.
The four main symptoms of narcolepsy are excessive daytime sleepiness, sleep paralysis, sleep hallucinations and cataplexy, which is a sudden, usually brief attack of muscle weakness related to a strong emotional response such as laughter, excitement or anger. Other symptoms can include troubled or fitful night-time sleep, frequent awakenings and nightmares.
The exact cause of narcolepsy is currently unknown but one of the strongest theories links it to the lack of hypocretins in the brain. Hypocretins are a form of neurotransmitter involved in the regulation of sleep and appetite in the brain. Studies involving dogs have found that placing new hypocretin cells in the brain restores the function that narcoleptic brains are lacking. There is no evidence that it is a mental disorder or has a psychological basis.
Symptoms of narcolepsy can be controlled through medication and behaviour modification. Stimulants are commonly prescribed to improve alertness, while antidepressants such as fluoxetine are prescribed to manage cataplexy, sleep paralysis and hallucinations. Regular exercise and abstaining from or limiting caffeine intake during the day will aid night-time sleeping and hopefully lessen the need for daytime sleep.
Secondary sleep disorders have an underlying cause related to either general medical problems or substances and drugs. For example, severe insomnia in the elderly is most often associated with arthritis, fracture, pain or depression. Another secondary disorder, obstructive sleep apnoea (OSA), is often linked to obesity and is one of the more common sleep disorders found on insurance applications.
OSA is a condition where the throat repeatedly narrows and closes during sleep. This blocks air from getting into the lungs causing breathing to slow down or stop completely - an apnoea. It is caused by collapse of the upper respiratory airways, which results in absent or reduced airflow, oxygen de-saturation and arousal from sleep. Often, this can lead to excessive daytime sleep, which can interfere with normal activities. The cessation of breathing can last as long as 60-90 seconds and can cause a blueness of the skin.
The most common factors contributing to OSA are obesity - a Body Mass Index (BMI) of over 30 - a narrow throat and being male. These three factors are interlinked as men especially can deposit fat in the neck, which causes a narrowing in the throat. Other factors include being aged over 40 - the throat becomes smaller with age - post-menopausal state, smoking, lung disease, large tongue, short neck and large uvula. Alcohol and sedatives contribute to the apnoea process as they relax the throat opening muscles.
Severe cases
Signs and symptoms of OSA include excessive daytime sleepiness, loud snoring, restless sleep, fatigue, depression, hypertension in an overweight male and a neck circumference of more than 42cm for men and 40cm for women. The highest standard for diagnosis is by using the overnight polysomnogram (PSG) which measures airflow, sleep stage, oxygen saturation and records ECG.
Weight loss and the reduction of alcohol intake and sedatives will reduce the severity of the condition. The application of nasal continuous positive airway pressure (CPAP) through a nose mask has proved the most effective treatment, but there is a problem with compliance as 20-40% of patients stop using it within three months. Intra-oral equipment such as tongue-retaining devices can be used in milder cases.
OSA will only carry a higher mortality risk in severe cases but this is usually linked to associated conditions. Disability is likely to be minimal unless there are vascular or functional complications. Daytime sleepiness may affect performance at work and social morbidity may occur if there is troublesome snoring or depression and irritability.
John Haseman is Life & Disability Underwriter at Scottish Equitable Protect
Sleep Disorders - the statistics:
• 40% of people with a sleep disorder have a concurrent mental illness or history of another mental disorder.
• An equal percentage of men and women suffer from narcolepsy.
• In the UK there are approximately 2,000 diagnosed narcoleptics, yet it is believed there are as many as 20,000.
• The incidence of narcolepsy ranges from five in 10,000 in Germany and North America, to 16 in 10,000 in Japan.
• People who have a first degree relative with narcolepsy only have a 1-2% chance of developing it themselves.
• The incidence of OSA is 4% in males and 2% in females.
• The Sleep Apnoea Trust estimates that around 300,000 people in the UK suffer from the condition yet only 30,000 have been diagnosed and treated.
• A family history of OSA doubles the risk.
• 30% of people with known coronary heart disease concurrently exhibit OSA.
Sources: Swiss Re; www.narcolepsy.org.uk; www.healthypages.net; www.netdoctor.co.uk; www.bbc.co.uk/health/conditions
Underwriting implications
When underwriting primary sleep disorders without an identifiable cause, underwriters will generally group them into mild, moderate or severe cases and assess whether there is any associated stress, depression/anxiety, daytime fatigue or obesity. The underwriter will also look at the applicant's driving record and occupation.
A General Practitioner's (GP) report will be required in the first instance when assessing a proposal with narcolepsy or cataplexy. An underwriter needs to consider the client's symptoms, results of all investigations, accidents, time off work, treatment and response to treatment, when assessing the severity of the condition.
For life and critical illness (CI) cover, insurance terms would not be offered until at least a six-month period from diagnosis. Providing adequate neurological investigations have been completed, terms would normally be offered at standard rates. Terms would not normally be offered for any disability benefit including income protection (IP) because of the effect the disorder can have on an individual's everyday activities.
When underwriting OSA, an underwriter will again request a GP report in the first instance in order to consider the treatment the client has had, the degree of oxygen saturation, frequency of symptoms, severity and duration of symptoms, any functional disorders, current evaluation of CVS including blood pressure and BMI.
For life cover, terms would normally be offered at standard rates unless CPAP treatment is not successful and the client is under 65 or symptoms are still persisting after surgery. If left untreated, any sleep-disordered breathing condition may increase the chance of heart attack and mortality. If there are additional factors such as COPD, obesity, hypertension or smoking then the appropriate rating would apply.
For CI cover, terms would normally be offered at standard rates providing there are no additional risk factors. If there are, then an extra rating of 25% would normally be added on top of the rating for the risk factor in question. For IP cover, where the client is looking for a four-week deferred period or no definite diagnosis has been made, then OSA or any associated complications can be excluded from the policy.
If a definite diagnosis has been made and the deferment period is 13 weeks or greater, then in many cases standard terms can be offered. Particular attention will be paid to the amount of time off work, occupation and any associated complications.
An IFA who has a client with a history of sleep disorders may find it useful to discuss the case with the insurance provider's underwriters before submitting the application.
