The term 'stroke' conjures up many disparate images to the general population. As it is an open and non-specific descriptive term it requires specific and careful definition for critical illness purposes.
Stroke is a major cause of disability in the UK and is the third leading cause of death in developed countries. Indeed, in the UK, someone has a stroke every five minutes.
The effects of stroke are widespread and vary from almost complete recovery to a state where sufferers require 24-hour care.
For critical illness purposes it is therefore necessary to come up with a workable and easy to understand definition of a stroke. The ABI definition is: 'Cerebrovascular incident resulting in permanent neurological damage, transient ischaemic attacks are specifically excluded.'
This short and specific definition leaves no doubt over the validity of any claim under the heading of stroke and limits payment of benefits to only those cases exhibiting lasting symptoms. Any misunderstanding of the scope of the cover usually occurs due to the fact that transient ischaemic attacks (TIAs) and many minor blackouts or 'turns' are labelled under the general stroke umbrella. This particularly happens in the elderly, when investigations undertaken may not be conclusive.
The causes of stroke
A stroke occurs when the oxygen supply (that is the blood supply via the cerebral arteries) to the brain is suddenly cut off causing damage to brain tissue. The episode normally occurs suddenly and without warning.
The three main causes of stroke are:
l Cerebral thrombosis the gradual formation of a clot within a cerebral artery, leading to complete blockage. This is similar to the disease process in heart disease; the arteries in the brain can be blocked due to being furred up by fatty material. The risk factors are very similar and well known, for example, high cholesterol, obesity, high blood pressure, diabetes, family history and smoking.
l Cerebral embolism the sudden blockage of a cerebral artery due to a piece of tissue or clot being dislodged from the vascular system and travelling through the body until it blocks an artery in the brain to form a plug, or embolism. Heart diseases showing irregular rhythm or heart valve damage usually cause these clots.
l Cerebral haemorrhage the bursting of an artery to the brain. Usually due to a weakness in the wall of an artery, termed an aneurysm, which is often the result of high blood pressure. Hamorrhagic strokes account for 10-15% of stroke cases.
Irrespective of the cause of the stroke the result will be death of part of the brain tissue, known as an infarction. This will have varying effects on brain function, depending on the part of the brain affected, causing the neurological symptoms. 10% of stroke survivors recover almost completely.
Having noted what causes stroke and stating that not all sufferers will be left with lasting problems, it is worth noting the following figures relating to recovery following the occurrence of a stroke.
l 25% recover with minor impairments.
l 40% experience moderate to severe impairments requiring special care.
l 10% require care in a nursing home or other long-term care facility.
l 5% die shortly after the stroke.
The limits of cover
So why is TIA excluded? A transient ischaemic attack is quite literally a transient and therefore short-lasting cerebral event, and although the symptoms are similar to those of stroke, recovery takes place within 24 hours. This is the whole key to claims under stroke is there permanent neurological damage?
As the title implies, by definition, one would expect a 'critical' illness to be a crisis in the individual's life. While the generic term stroke does indeed include TIA, if we consider the impact on a person's life and the cost implications of including what would be seen as a non-critical event it is a logical step to exclude TIA from the cover.
The purpose of critical illness benefits are to enable the claimant to provide finances to make any necessary living changes following serious illness, or to make provision for any family protection or financial liabilities. This must be at reasonable cost and the provision of cover for less serious illnesses that may not have a major effect is not what the product is designed or costed for.
Although TIA is not covered it should be noted that this is often an early warning sign of stroke because about one third of those who suffer TIA have a stroke within five years.
The five most common symptoms of stroke are:
l Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. This is termed hemiparesis, and is present in 75% of cases.
l Sudden confusion, trouble speak- ing (dysphonia), or understanding (dysphasia).
l Sudden difficulties seeing in one or both eyes.
l Sudden problems in walking, dizziness, loss of balance or co-ordination.
l Sudden severe headache with no known cause.
It can be seen that the symptoms of stroke must be sudden and no one is ever prepared for this potentially disastrous event. If the above symptoms were of gradual onset another cause would normally be identified.
Diagnosing a stroke
To be considered permanent the opinion of a consultant neurologist would usually be sufficient. While many stroke sufferers will show ongoing and steady improvement in function with adequate support, if the neurological damage is termed permanent then a claim would be admitted despite any anticipated progress.
The purpose of investigation is to identify the cause of the patient's symptoms. Clinical diagnosis will be fairly straightforward based on the patient's physical symptoms. However, as it is important to establish the cause of the stroke the patient will undergo various investigations to clarify the extent of any artery disease and an appropriate course of treatment.
The cornerstone test is a CT scan as this will not only rule out other possible causes (for example, brain tumour) for the patient's symptoms but would also confirm whether the stroke is due to a clot (ischaemic stroke) or bleeding (haemorrhagic stroke) and hence the treatment required. Other tests could include an ultrasound scan that uses sound waves to look at the arteries in the neck and see if there is any blockage to the blood flow.
Treatment will be two-pronged based on rehabilitating the patient for example, physiotherapy, psychiatric support and preventing further stroke through dietary advice or scrupulous blood pressure control.
Age risks
Stroke is often considered to be a condition of the elderly. This is probably due to the fact that in the developed world we have an ageing population, and although the stroke risk does indeed increase with age the following facts demonstrate the value of cover against stroke:
l The risk of stroke doubles with each decade above age 35.
l One third of all strokes occur before age 65.
l Stroke is the largest single cause of severe disability in the UK, affecting more than 300,000 people. Each year more than 100,000 people in England and Wales have a first stroke.
Following a stroke, a survivor may require long-term assistance with basic living activities such as mobility, dressing, toileting, eating and communication.
There are ways in which a stroke victim can be assisted in the road to recovery or be helped to ease the burden of everyday tasks. Physical aids, personal care assistance and modifications to homes may help the stroke victim return to an acceptable standard of living and this all represents major financial burden. Even if the sufferer is able to live independently it may well have been necessary to retire from employment and critical illness benefit could provide a substantial lump sum to ease the financial impact and can be used for any purpose.
Stroke is indeed a major incident, however it is possible with rehabilitation and support from both medical and family networks that a stroke survivor can become as independent as possible with time. This can be accomplished in such a way to preserve dignity and motivation to re-learn basic living skills. The role of critical illness protection in this overall scenario could well be considered a major supporting factor.
Alan Marquis is life and disability underwriter at Scottish Equitable Protect
