May 2000 Are Clients with Hepatitis C Insurable? Join RiskTutor on Tuesday, June 6, 2000 at 3:00 p.m. EST in a live online forum that will explore the following issues regarding Hepatitis C: What is the critical information you need to determine the insurability of clients with a history of Hepatitis C? What are the blood tests used to make the diagnosis of Hepatitis C? Who need to have a liver biopsy? How is Hepatitis C treated? How successful is the treatment? Should everyone with Hepatitis C be treated? What is the best way to present a Hepatitis C case to a life insurance company? You can register for the free forum either in advance or the day of the event at: http://www.brokerville.com/liveforum.asp Lab Studies Used In Diagnosis & Monitoring | Drug Treatment | Underwriting Comment Alzheimer's Disease Alzheimer's disease is a progressive, neurological disorder that attacks the brain and results in cognitive problems, such as memory loss, impaired thinking and strange behavior. Overview of Alzheimer's Disease: Approximately 4 million Americans have Alzheimer's disease. One in 10 persons over 65, and nearly half of those over 85 have Alzheimer's disease A person with Alzheimer's disease lives an average of 8 years and as many as 20 years or more from the onset of symptoms. Alzheimer's disease is the 4th leading cause of death in the United States. More than 7 out of 10 people with Alzheimer's disease live at home. Half of all nursing home patients suffer from Alzheimer's disease or a related disorder. Diagnosis of Alzheimer's Disease Alzheimer's disease is not just memory loss. People with Alzheimer's disease experience a decline in cognitive abilities such as thinking and understanding as well as changes in behavior. The Alzheimer's Association has developed the following 10 "warning signs" that may be aid in the diagnosis of Alzheimer's disease: Memory loss that affects job skills. Difficulty performing familiar tasks. Problems with language. Disorientation to time and place. Poor or decreased judgement. Problems with abstract thinking. Misplaced things. Changes in mood and behavior. Changes in personality. Loss of initiative. IMPORTANT NOTE: Currently, doctors cannot diagnose Alzheimer's disease with 100% certainty until a brain autopsy after the person's death reveals the disease's markers: abnormal clumps and irregular knots of brain cells. However, a more powerful version of MRI, called magnetic resonance microscopy, may be able to detect the abnormal protein deposits of Alzheimer's disease in live patients. While this is only a preliminary finding, it suggests that scientists are moving closer to developing a single test to detect Alzheimer's disease. Given that there is no single test that can be used to identify Alzheimer's disease, the diagnosis of Alzheimer's rests largely on the judgment of physicians experienced in dealing with dementing illnesses. But that judgment has become quite sophisticated. Experts estimate current diagnostic accuracy at around 90%. Evaluation of clients with suspected Alzheimer's disease usually included the following items: Complete health history Physical examination Neurological and mental status assessments Blood and urine tests EKG CT of MRI imaging of brain IMPORTANT NOTE: There is a form of memory loss somewhere between that associated with normal aging and that of Alzheimer's disease that has been termed MILD COGNITIVE IMPAIRMENT (MCI). Individuals with MCI have memory loss but only mild cognitive impairment (i.e. they do not meet the criteria for the clinical diagnosis of Alzheimer's disease). Individuals with MCI appear to be at increased risk for developing Alzheimer's disease. The prevalence of MCI in the general population is unknown. There is currently a nationwide Memory Impairment Study to study MCI and the effect of different therapies to slow the development of Alzheimer's disease.   Treatment of Alzheimer's Disease The medical and social management of Alzheimer's disease is expensive and stressful to both the patient and the caregiver. In addition to treating the symptoms, difficult issues regarding the location and type of health care for the patient must be addressed. While family and friends provide almost 75 percent of home care for Alzheimer's patients, at some point in the illness home care may no longer be possible. The major challenge in managing Alzheimer's disease is behavioral symptoms. Some individuals become anxious or aggressive, while others repeat certain questions or gestures. Some of the most common problematic behaviors are: Agitation Aggression Combativeness Suspiciousness/paranoia Delusions Hallucinations Insomnia Wandering Behavioral symptoms are usually handled using a combination of nonpharmacological and pharmacological treatments. Nonpharmacological Treatments The following are important nonpharmacological strategies for managing Alzheimer's patients: Family education and counseling It is important that caregivers learn what to expect when caring for someone with Alzheimer's disease. It is equally important for the patient to know what to expect as the disease progresses. Modifying the environment Each personality responds differently to their immediate environment. Lighting, color, and the noise level can all impact behaviors. The goal is to modify the environment in a way to reduce confusion, disorientation and agitation. Planning activities Planning activities (i.e. personal hygiene as well as creative leisure activities) can play an important role in providing both stability and independence to the Alzheimer's patient. As important, they can also relieve depression, agitation and wandering Pharmacological Treatments There are currently two FDA-approved medications for treating Alzheimer's disease: Aricept (donepezil) Cognex (tacrine) A third drug, Exelon (rivastigmine), received an approval letter from the FDA and is expected to be available sometime in 2000. A fourth drug, Reminyl (galantamine) is under FDA review. None of these medications will cure Alzheimer's disease and they do not stop the progression of the disease. They are intended for individuals with "mild to moderate" Alzheimer's disease and they appear to improve cognition, general function and behavior. IMPORTANT NOTE: Both Aricept and Cognex have side effects and not all patients benefit from taking either medication. Individuals taking Cognex must be monitored regularly for liver damage. There are other medications, not specific for Alzheimer's disease, which may be used to treat the problematic behaviors of Alzheimer's disease. These include: Brand Name Brand Name Haldol Xanax Zyprexa Buspar Seroqeul Valium Risperdal Ativan Elavil/Endep Prozac Wellbutrin Luvox Norpramin/Pertofrane Serzone Pamelor/Aventyl Paxil Zoloft Desyrel With the aging of the U.S. population, concerns over memory loss and its implications will become a common underwriting concern. While it is true that client’s who have been diagnosed with "probable Alzheimer’s disease" are uninsurable for individual coverage, other client’s with mild memory loss may, in fact, be insurable. The following is a list of screening questions that will help you better assess your client’s insurability: Is the client "suspected" of having Alzheimer’s disease or has the client simply been noted to have memory loss? There are many causes memory loss and memory loss alone is not sufficient to warrant a diagnosis of Alzheimer’s disease (see discussion above on MCI). There is a long list of medical problems that must be ruled out first before memory loss combined with cognitive problems can be labeled Alzheimer’s disease (see the Dementia/Alzheimer’s Disease screening questionnaire for a list of these medical problems). Does the client live alone? Caring for oneself is a complex process especially at older ages. If a client lives alone and manages all of their normal affairs, then the suspected dementia is probably mild. If the client needs full time assistance or needs to live in an assisted living environment, then the suspected dementia is most likely more severe. Clients who need an assisted living environment, at home or in an institution, due to suspected dementia (any form) are uninsurable for individual coverage. Does the client’s condition appear to be deteriorating? Clinical stability argues against progressive causes of dementia like Alzheimer’s disease. It is important to find out if the memory and cognitive problems are getting worse or have remained the same for an extended period of time. Does the client drive a car and manage their finances? Driving a car and managing personal finances represent the highest level of ADLs (activities of daily living). If a client can continue do both of these, then any suspected problems with memory loss of cognitive functioning are presumed mild. What medications is the client currently taking? Clients who are taking Aricept of Cognex are presumed to have been diagnosed with Alzheimer's disease (see Pharmacy Tutor for further details) Coming in the June 2000 RiskTutor Online Newsletter: Ulcerative Colitis