The Truth about Statins and Seniors

I recently came across an editorial which reviewed the benefits of statin therapy in older aged individuals in the October 2011 Journal of the American Geriatrics Society. I wanted to provide some "highlights" from this enlightening review of several cholesterol studies which sought to shed some light on the value of lower cholesterol levels in the elderly. What was revealed in the study was that there is actually protective value in higher total cholesterol and non-high-density lipoprotein levels. Even more revealing, is that there have not been any studies to date displaying any benefits in persons over the age of 80 to utilize statin therapy unless they have documented coronary atherosclerosis.

Review of various studies indicated that there is strong association between higher cholesterol levels in the elderly with lower risk of non-cardiovascular disease and total mortality. Lower cholesterol levels have been strongly associated with higher all cause mortality and is utilized as a measure of "frailty" in the elderly. A large study of over 19,000 individuals, aged 65-82, found relative risk reduction of all cause mortality of 22% in statin therapy users vs. non-users. There was also associated protective value of statin therapy against dementia for the "middle aged" but on the flip side there was a notable increase in cognitive issues in the elderly utilizing this therapy. Additionally at older ages there are strong adverse issues related to individuals with fall histories, increased incidences of depression, symptoms of intolerance (muscle aches and gastric symptomology), and significant concerns related to poly-pharmacology.

As with most studies on the subject, there are pros/cons related to the use of this therapy. Not quite the "wonder drug" touted by some, especially in our aging population. As with any therapy, "one size does not fit all " and caution should be utilized when assessing mortality risk (or improvement) when it comes to statin therapy and the elderly!

"I find that a great part of the information I have was acquired by looking up something and finding something else on the way"

Franklin P. Adams (1181-1960)

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"Keys to Longevity" - The Adventist Advantage

I've been reading a fascinating book by Dan Buettner on "Blue Zones" in the world that boast higher than average pockets of individuals living well into their 90's and beyond (amazing Centenarians!). The book explores common lifestyle and genetic factors that contribute to longer than average life expectancies.

One U.S. demographic that was explored was the Loma Linda Blue Zone -specifically a concentrated area of 7th Day Adventists. In 2001 Loma Linda University released the results of a longevity study of SAD's in the Loma Linda area. It was a comprehensive study that followed 34,000 individuals over 12 years and focused on specific lifestyle factors based upon SAD practices-which indicated statistically significant increases in life expectancy. Compared to the average Californian, Adventist women exceeded the average life life expectancy by 6 years and Adventist men exceeded the average by nearly 10 years!

Dan Buettner and his National Geographic research team (funded by the National Institute of Health) completed additional focused longevity research on the phenomenon of the Loma Linda SAD group-the results further documented increased life expectancy (of 6-10 years) based upon an emphasis on health, diet, and sabbath observance.

Lifestyle benefits specifically uncovered by Buettner incorporated the following practices;

• Following a vegetarian lifestyle-on average a vegetarian status (specifically non-meat eater) will gain the average person 2 years of additional life expectancy


• Eating nuts-largely related to heart disease prevention, another 2 year gain


• Being a non-smoker-Even a past smoker is at moderate risk of lung cancer and heart disease


• Physical activity-mild amounts of daily activity provide another 2 years of average life expectancy with benefits directly related to heart disease and cancer prevention (specifically breast and colon). There is a wear-off point in activity where the benefits flatten out-such as for those marathoners (I always think of Jim Fixx as being a stand-out exception to the rule)


• Maintaining a healthy weight-increased weight is associated with obvious impacts on heart disease, diabetes, and respiratory issues. One area being further evaluated by the research community is an increase in active chemicals in the body which may increase cancer risk, chemicals that appear to come from excess fat cells. Vegetarians on average are 16 pounds lighter than their non-vegetarian friends.

It appears that there are clear longevity benefits to the Adventist lifestyle-many points which reflect similarities to other longevity studies I've followed over the years. Our individual genetic make-up only provides about a 20% benefit leaving a significant, and necessary, focus on our lifestyles.

"Most of the change we think we see in life is due to truths being in and out of our favor"

Robert Frost (1874-1963), The Black Cottage

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Living to 100-Revelations of the Longevity Project

So, like most Americans do you believe that "good genes" coupled with a healthy lifestyle-eating right, maintaining a healthy weight, refraining from "high risk" activities, and 30 minutes a day on a treadmill will equate to a long life expectancy? Well, that "myth" is being dispelled by several different researchers that have identified, in separate studies, that social activity has more impact in longevity than our genes for one thing!

I recently read a book titled "Blue Zones-Live Longer, Better" by Dan Buettner. He focused on similarities in areas around the world which are "pockets of longevity"-higher than average populations of seniors living past 100. The primary message-living a happier and purposeful life is one of the secrets to a longer than average life. As an example, the average American could expect to live an additional (12) more years and increase their "happiness" by 40% with lifestyle optimization and making changes in their environment.

A new book coming on the heals of Blue Zones, but suggesting very similar findings, is "The Longevity Project". The researchers from Stanford University provide insight into study findings after following 1500 participants and compiling eight decades (yes-80 YEARS!) of data on older ages which suggests that the key to unlocking a long life are related to a life filled with purpose, not running on the track. Here are some of the key findings explored in living to 100;

• Set clear-sighted goals


• Work hard at ones job


• Worry in moderation


• Maintain strong and stable relationships

Oh, and as for relying on your perfect genetic baseline helping you out-the truth is that it only provides about a 20-30% impact. Environmental and social factors clearly have the upper hand in ones mortality.

"Here's to a long life and a merry one. A quick death and an easy one. A pretty girl and an honest one. A cold beer and another one!"

Old Irish Saying-and fitting at that!

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Ask the Underwriter: "Should I order paramedical exams on my life settlement applicant?"

Recently, I was asked about the value of life insurance paramedical exams and the potential value in life expectancy underwriting. It seemed like a good opportunity to explore the use of additional medical data sources in that process and focus on where the "protective value" truly lies.

Over the past six years I've had the opportunity to learn a lot about the secondary market -the interesting world of life settlements. In particular the medical information utilized to assess risks and assign the critical "life expectancy estimation" numbers stands out as an ongoing area of perplexity. By that I mean that in my two decades of underwriting life insurance risks, primarily focusing on affluent, senior market lives, it is confounding to me that with all of the "tools" available to carriers and reinsurers to properly vet mortality risk, only one tool has historically been utilized in the life settlement market, which is review of medical records. In a market where substantial financial risk is being undertaken by investors, they are skimming the surface of understanding the mortality impact of the policy (ies) they are vying for. I believe the reason for this is two-fold; (1) investors are not properly educated on the underwriting tools available and their "protective value", and (2) obtaining LE certificates has largely fallen on the shoulders of providers and brokers who absorb the cost of ordering medical records and LE's-hence the cost of additional underwriting requirements is not one that most want to take on.

So, what is "protective value" in the sense of underwriting assessments and of all the underwriting tools available which ones make the most sense in evaluating LS individuals? Protective value in underwriting relates to data gathered on an applicant that provides enough relative information to appropriately assess that individuals mortality risk that the carrier will be on the hook for at time of a claim. The goal is to obtain the right amount of information without incurring undue cost, not always an easy task as risk assessment tools available range from paramedical/MD exams to full medical records, from standard panel blood profiles to specific diagnostic tests, resting EKG's to treadmill testing, and from telephone interviews to extensive investigative reports including credit and background checks.

When it comes to life settlement risks, with a focus on affluent seniors, the following risk assessment tools will undoubtedly provide the best "protective value" for investors;

• Medical records; covering the past (5) years of history from the primary attending physician and specialists (i.e. cardiologist)


• Senior risk assessment (thorough on-site assessment) or senior risk questionnaire (telephone interview completed by an senior risk underwriting expert)


• Current blood profile with specific tests that reflect direct mortality impact

These specific underwriting tools will provide an additional layer of data that will enhance the underwriting assessment and provide a more robust LE certificate (i.e. the protective value that investors can be confident in). The average cost per life will be $1000.00 (exclusive of LE assessment) which is minimal given the financial risk investors are taking on.

I hope this brief overview will provide you with insight into options and opportunities to enhance the life expectancy process. This is the first of what I hope will be many "Ask the Underwriter" discussions-please continue to submit your questions about the largely misunderstood world of medical underwriting!

"Take calculated risks. That is quite different from being rash."

General George S. Patton (1885-1945)

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Statin Drugs- "Read the Fine Print"

Statin drug therapies have been touted as the most effective treatment for not only slowing the progression of atherosclerotic disease but also key in preventing development of disease by lowering the effects of increased levels of cholesterol. Cardiovascular disease still ranks as the #1 leading cause of death in the U.S. with strokes running a close 3rd-so it makes sense that from the time statin drug therapies were introduced (approximately 2003) there has been a continued rise in prescriptions and even insight into the broader uses of statins as a preventative therapy.

While there has been a focus on all of the positive aspects of statin use, often times the issues surrounding this therapy have been overlooked. There are a number of issues related to statin drug therapy that have prevented many individuals (especially seniors) from utilizing these drugs. Some of the minor issues, that do relate to lack of "tolerance" and use of the therapy long term include; muscle weakness, abdominal cramps, and general athralgias. More severe, and compromising issues include liver function abnormalities, acute renal failure, and heart muscle damage. A news release today indicated an FDA warning against increased uses of one particular statin drug (Simvastatin-sold under the brand name Zocor) at increased levels due to muscle (heart) damage.

There has been a trend by clinicians prescribing this drug therapy to prescribe amounts in excess of acceptable limits (if good is good, than more must be great!) with increased utilization in otherwise healthy individuals. Independent studies have shown that utilizing statin therapy as compared to a placebo show no statistically differences in reducing cardiovascular morbidity and mortality.

For underwriting risk assessment purposes, it does seem reasonable to apply "credits" to those heart patients that have been on long-term statin therapy that have notable stability and control of their lipid levels. It stands to reason that applying mortality improvement across the actuarial curve does not "make sense" given the broad based issues noted with current statin therapies and the lack of long-term mortality/morbidity data related to this therapy.

"A strong positive mental attitude will create more miracles than any wonder drug"

Patricia Neal

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Positive Movement in Life Insurance Activity

MIB-Medical Information Bureau posted their April index which indicates continued gains in individually underwritten life insurance applications. Typically a month that trends down due to normal seasonal fluctuations, this April posted gains for the first time in seven years!

Reflecting a +1.1 gain, older ages (60+) continue to lead the pack with a year-over-year gain of +8.4% but there is surprising increased activity in the middle group (ages 45-59) of +1.0% which has posted positive numbers four months straight.

This information comes on the heels of my travel to a major underwriting industry meeting (AHOU) where underwriting managers and executives seemed positive and upbeat about the increased business they were seeing on their end. Many attributed growth to a renewed marketing and product focus on middle-markets (average death benefits of $1MM) directed at Gen X'rs and continued expansion of simplified products pointed at the baby boomer market.

Trends that require continued monitoring for those active in secondary markets as this will undoubtedly change the future landscape of policy settlements.

"Spring is a true reconstructionist"

Henry Timrod

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It's All in the Genes!

I just read a fascinating article posted by Reuters this weekend about (13) new genes identified by English researches which have a direct correlation to increased risk of coronary artery disease. Researches feel these genes are the key to unlocking how the disease develops and preventative therapies that can be instituted early on in a high risk individuals life to stop the development of the disease.

Clinical researchers, although excited about the future prospects of identifying specific genetic patterns, are realistic about the fact that they are years off from truly pulling all of the pieces together that will be needed to put changes into preventative therapy into action and even longer before we start seeing decreases in cardiac related deaths-still the leading cause of death in the world according to statistics from the World Health Organization (WHO).

Often times I am asked what part genetic testing can, and will play in medical underwriting and longevity. I've watched the focus on DNA testing and followed clinical research studies over the past several years and see the impact to underwriting being years off. From a life insurance perspective stringent GINA (Genetic Information Nondiscrimination Act) regulations do not allow insurers to take negative action on a proposed insured based upon DNA results. For life settlement, where we look at longevity not issuance of a policy, we know that an individuals genetic predisposition accounts for less than a 20% mortality impact vs. lifestyle which accounts for over 80%! Where underwriters will first see the impact of DNA testing is in more individualized preventative and specific impairment treatment options for patients that will positively impact that individuals morbidity and mortality. To read this Reuters article follow me on twitter!

"As for me, except for an occasional heart attack, I feel as young as I ever did"

Robert Benchley, 1889-1945

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MIB Activity Index-Tick Up In Activity

Medical Information Bureau (MIB) recently reported it's life insurance activity index for December 2010 and summation of 4Q results. December, historically being a high volume month associated with "year end push" in life underwriting departments across the board noted that December 2010 -although reporting a shortfall-was still an improvement over notable market declines experienced over the past 4 years. December closed at -1.2%-all ages combined. Prior years have had an annual decline run rate of -3%, December 2009 -0.2%.

MIB CEO, Lee B. Oliphant, provided further insight into the numbers indicating that 2010's "modest decline demonstrates resilience in the markets compared to the past".

4th Quarter results noted a surge in applicants aged 45-59 (a demographic that has suffered along with the economic decline over the past several years), seniors in the 60+ group continued to drive the market which has been a relatively consistent trend over the past several years.

What does this mean to this blogger? The increase in applicants 45-59 is a stand-out, it reflects that there is a feeling of increased market confidence -no matter how small-keeping in mind that for most individuals life insurance is still considered a "luxury" item, not a necessity.

"The most beautiful thing we can experience is the mysterious. It is the source of all true art and science" Albert Einstein

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