There are 750,000 dementia sufferers in the UK. David Butler explains the varying degrees of this cruel condition
Compared to just 15 years ago, people in the developed world are living longer. This can be explained by several social factors such as better public healthcare, better education, nutrition, safer environments and improved housing.
The 'greying' of society gives insurance companies something else to think about. Older people are often more financially astute and seek to ensure all their financial affairs are in order. This can result in obtaining further insurance to cover all aspects ranging from inheritance tax liability to protection plans or insurance to provide long term care.
With this increase in older lives, underwriters must be aware of certain conditions that become prominent in old age, with symptoms that could be evident much earlier. One such condition is dementia.
Dementia is generally a condition associated with old age, therefore normally becoming identifiable over the age of 65. It is not a single disorder, but is the description of the decline in all aspects of memory and the associated emotional and behavioural changes.
There are a number of different types of dementia, each with slight differences. An underwriter will need to know the signs and symptoms associated with the different conditions and apply their knowledge to offer terms where applicable.
n Alzheimer's dementia
This is a degenerative condition, associated with the loss of brain cells, within a number of areas in the brain. Unfortunately the cause and reason the condition exists are not completely understood. However, dementia can be identified if signs of inflammation and deposition in plaques within the grey matter are evident on investigation.
As a result of brain cell reduction, there is a severe loss of intellectual function. The disease progresses along an irregular path with initial symptoms likely to be failure of memory, especially for recent events, and decreasing efficiency at work or at home.
n Fronto-temporal dementia (Pick's disease)
This type of dementia involves the wasting and loss of substance to the frontal and temporal areas of the brain. However, the same disease changes that are evident in Alzheimer's dementia do not show on investigation.
More common in females than males, the disease is less common than Alzheimer's. Signs of this condition are severe problems in language, attention or behaviour.
n Creutfeldt-Jakob disease (CJD)
CJD has received recent publicity under the synonym, 'mad cow's disease,' but how much is known about the condition?
There are two forms of the condition, human and bovine spongiform encephalopathy.
The human condition can be transmitted through transplants and can appear to be of low infectivity and stay in the body for a long period of time before showing any signs of disease. The bovine form is transmitted to people by eating infected meat products.
Whether it is the human or bovine type of CJD, the consequences and symptoms are normally the same.
Once diagnosed, the condition causes the overgrowth of the brain connective tissue. This results in the dementia, involuntary movements and abnormal brain activity present through the degeneration of the brains cells. The symptoms develop between the ages of 40 and 60 and normally leads to death within one year.
n Mild cognitive impairment (MCI)
Instrumental activities of daily living (IADLs) are used when diagnosing MCI. The IADL can be described in general terms as home management, and other tasks which require motivation, co-ordination and intact cognition. Examples are telephone use, preparing meals, organising finances and other everyday tasks taken for granted.
When MCI is diagnosed there is no real affect on the IADLs, but memory complaints become apparent. This does not necessarily mean dementia can be diagnosed, but between 12% and 15% of people diagnosed with MCI will progress to Alzheimer's dementia each year. An underwriter would need to see full investigations carried out if MCI had been confirmed. Any reduction in the IADLS would highly suggest dementia.
n Vascular dementia
This condition occurs when there are a number of cerebral strokes (infarcts) over a period of time. Therefore someone with a history of raised blood pressure, smoking or other cardiovascular problems could be a higher risk for vascular dementia. Symptoms are similar to those found in alzheimer's dementia and separating the two conditions is not always easy.
Due to the strong link with cardiovascular problems there is an increased risk of fatal heart attack.
n Lewy body dementia
Lewy bodies are a characteristic associated with Parkinson's disease. They are found in up to 20% of those with dementia. The course of the condition runs a similar course to Alzheimer's dementia.
n Normal pressure hydrocephalus
A history of meningitis, stroke or head injury could be a predisposing factor in the condition, normal pressure hydrocephalus. It is caused by a reduction in the reabsorption of the cerebrospinal fluid by the venous system. This reduction in the fluid causes abnormal pressure waves which then lead to a flattening of the cerebral cortex and dilatation of the brain ventricles. As the cortex is the most highly developed part of the brain, any damaged caused is not good news.
How is the condition diagnosed and can the dementia be treated?
Investigations into the condition can be extensive. CT and MRI scanning techniques can indicate any changes in the formation of the brain and distinguish between Alzheimer's and vascular dementia. An electro-encephalogram (EEG) can identify variants of CJD and brain biopsy can provide information relating to plaques linked to Alzheimer's or Lewy body dementia and Parkinson's.
The treatment associated with dementia is changing all the time. New drugs are being developed, but rather than slow the progression of the disease, they tend to work on improving the quality of a person's life and ability to live as they did before.
With this is mind the speed at which a dementia type progresses can be fairly rapid. On average, people with Alzheimer's live for about seven years after diagnosis. CJD can dramatically lead to death and vascular dementia greatly increases the risk of heart attack.
Alzheimer's disease, CJD and other types of dementia are core critical illness conditions, and with this product being at the forefront of the protection market, an underwriter must ensure any early signs of these conditions are fully investigated.
David Butler is a life and disability underwriter for Scottish Equitable Protect
Underwriting implications
Should an applicant exhibit any signs or symptoms of any dementia, an underwriter will inevitably request a report from the GP to ascertain whether terms can be offered. The information required will be:
n Has a definite diagnosis of dementia been made.
n What is the cause of the dementia.
n Is there cognitive impairment.
Once the above has been established, and the evidence considered, the application will invariably be declined. Overall dementia, as stated previously, is a degenerative condition with associated risk factors of premature death, depression, physical illness, speech disturbance and increased risk of fatal heart attack.
If there has been a definite diagnosis of Alzheimer's fronto-temporal, or vascular dementia, CJD or BSE then all applications would be declined by the underwriter.
For applicants aged over 75 diagnosed with MCI, cases would be considered on a individual basis. Applicants under 75 with the diagnosis would not be offered cover of any kind.
All cases of dementia will be assessed individually and in certain instances, will be discussed with the Chief Medical Officer. However, invariably the decision will be declined.
