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Neurological Disorders

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Out of approximately 2000 claims seen in a 12 month period by Swiss Re ... Asymptomatic carotid bruit 1.5. Asymptomatic carotid stenosis 2. Atrial fibrillation 5 ... – PowerPoint PPT presentation

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Title: Neurological Disorders


1
Neurological Disorders
Handling claims
2
Agenda
  • Introduction - claims and underwriting
  • Epilepsy
  • Multiple Sclerosis
  • Stroke
  • Head Injury
  • Parkinsons Disease

3
Introduction
  • Why are neurological claims so important
  • Out of approximately 2000 claims seen in a 12
    month period by Swiss Re
  • 6.5 were attributable to Multiple Sclerosis
  • 5.9 were attributable to CVA

4
Claims Report 2000 Swiss Re Life Health
5
Claims Report 2000 Swiss Re Life Health
6
Statutory benefits increasingly expensive
  • DLA 1.1m people in 1992 2.1m in 2000
  • Cost of DLA 2 billion in 1992 6 billion in
    2000
  • Claimants awarded attendance allowance increased
    by 45, and cost doubled 1992-2000
  • Too much avoidable physical and psychological
    disablement from lack of rehabilitation services,
    and delayed or ineffective management of
    treatable disease (DLAAB 1998)

7
Factors governing benefits
  • Offer of rehabilitation to those with DLA is a
    threat to their income
  • The money rewards failed function, but does not
    reward functional gains made through
    rehabilitation
  • A change of culture is needed benefits should be
    structured to encourage a return to normality, or
    at least to useful function in society.

8
Epilepsy - 1st seizure
  • Variables Age lt50, nocturnal sz, FH of Ep or
    febrile sz
  • no variables 18 recurrence
  • one variable 31
  • two variables 42
  • three variables 60
  • At one year after presenting seizure
  • Hopkins et al 1988 Lancet

9
Multiple Sclerosis
10
Diagnosis of Multiple Sclerosis
  • A definite diagnosis of Multiple Sclerosis can be
    made if the disease process fits either of the
    following criteria
  • (i) Two attacks and clinical evidence of two
    separate lesions OR
  • (ii) Two attacks clinical evidence of one lesion
    and paraclinical evidence of another separate
    lesion.
  • The two attacks must involve different parts of
    the central nervous system, must be separated by
    a period of at least one month and must each last
    a minimum of 24 hours.
  • However, certain historical information may be
    substituted for clinical evidence of one of the
    two lesions.

11
Multiple Sclerosis - difficulties in diagnosis
  • Fatigue
  • Visual disturbances
  • Neuralgia
  • Neuritis
  • Post-viral syndrome
  • Transverse myelitis
  • Vertigo
  • Positive Family History
  • Two episodes of neurological symptoms

12
Prognostic indicators
  • Lesion load on MRI scanning
  • Symptoms at onset
  • Number of attacks
  • Recovery
  • Age
  • Sex

13
Clinical Progression of Multiple Sclerosis
Compston A, Coles A. Multiple Sclerosis. Lancet
April 2002 359 1221-1231
14
Multiple Sclerosis
15
MRI scan showing typical cerebral multiple
sclerosis
16
MRI Scan of spinal cordshows areas of
demyelination
17
Multiple Sclerosis -
Claim criteria
  • A definite diagnosis by a Consultant Neurologist
    of Multiple Sclerosis which satisfies all of the
    following criteria
  • There must be current impairment of neurological
    function, which must have persisted for a
    continuous period of at least six months
  • The diagnosis must be confirmed by diagnostic
    techniques current at the time of the claim

18
New Diagnostic Criteria for Multiple Sclerosis -
what are the implications for insurers ?
Compston A, Coles A. Multiple Sclerosis. Lancet
April 2002 359 1221-1231
19
Daily Mail Wednesday April 17 2002
20
New therapies and diagnosis
  • Diagnosis is now made earlier
  • Beta-interferons modify course and disability
  • New therapies are coming
  • Diagnosis will be made even earlier in future

21
MS risk - familial
  • brother 2
  • sister 4
  • child of conjugal pair 6
  • identical twin 25
  • non identical twin 3
  • sister of MS female 6
  • child of MS parent 3

22
Risk of MS in Northern Europe
  • overall risk 1 600
  • child of one affected parent 1 200
  • affected sibling 1 40
  • child of two affected parents 1 17
  • affected identical twin 1 3(age-adjusted
    risks are greater)

23
prognosis
  • disease less active after 1st year
  • early relapsing-progressive course has worse
    prognosis
  • generally 2nd year less relapses than first
  • patients generally underestimate their disability
  • more frequent relapses incur greater lesion load
  • relapses more frequent in cases seen at onset
  • early progressive course also bad prognosis
  • men more active disease than women
  • DSS 3 reached in 1.4 yrs
  • DSS 6 in 4.5 yrs
  • DSS 8 in 24 yrs

24
Definition of stroke
  • Stroke is defined as an insult to the central
    nervous system on a primary vascular basis.

25
Major Blood Vessels of the brain
26
Classifying Stroke
  • TIA less than 24 hrs deficit
  • Lacunar infarction may be small and subclinical
    pontine and capsular lacunes cause symptoms
  • Major arterial occlusion
  • Intra-cerebral haemorrhage

27
Lacunar infarct
28
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29
Carotid disease
30
Causes of Stroke
31
Stroke - relative risk
  • Hypertension 4 - 5
  • Smoking 1.5 - 3
  • Atrial fibrillation 5 - 7
  • Diabetes 1.5 - 2
  • Alcohol abuse 1 - 4

32
Stroke risks (/year)
  • Aged gt70y 0.6
  • Asymptomatic carotid bruit 1.5
  • Asymptomatic carotid stenosis 2
  • Atrial fibrillation 5
  • AF after minor stroke 12
  • Isolated TIA 6
  • (12 1st year and 30 at 5 years)
  • TIA with carotid stenosis 13
  • Previous ischaemic stroke 9

33
Aspirin in stroke
  • Reduces stroke rate from 10.2/y to 8.2/y (23
    odds reduction)
  • Not so effective in absence of risk factors for
    stroke
  • AF stroke risk reduced by 70 with warfarin - but
    risky if gt75y
  • Carotid endarterectomy - an evolving story

34
Increased stroke risk
  • Smoking (double)
  • Associated with myocardial ischaemia, and cardiac
    arrhythmias (AF)
  • Family history of vascular disease
  • Hypercholesterolaemia (screen lt45yrs) - MI risk
  • Migraine
  • Diabetes mellitus (2x)
  • Hypertension (linear 4x if diastolic gt 100mmHg)

35
Cellular Injury during Ischaemia
36
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37
Overall Stroke outcome
  • 45 independent
  • 25 dependent on others
  • 30 dead
  • Better outcomes with small strokes, posterior
    circulation strokes, lacunar strokes

38
Stroke - rehabilitation
  • Can improve disability and handicap, but not
    neurological deficit
  • Manage and prevent depression
  • Actual benefit of rehabilitation programmes is
    difficult to quantify, because the interventions
    are multifactorial

39
Stroke - avoidable disabilities
  • Frozen shoulder
  • Contractures
  • Falls causing injury
  • Corneal abrasion
  • Pulmonary emboli

40
Stroke recovery - better if
  • Rapid immediate phase of recovery
  • Pure motor stroke
  • No speech involvement
  • No incontinence
  • Younger age
  • No cerebellar features
  • Never unconscious

41
Stroke - claim criteria
  • A cerebrovascular accident resulting in permanent
    neurological damage. Transient Ischaemic Attacks
    are specifically excluded.

42
Permanent Neurological Damage?
  • Confusing term..
  • Do we mean permanent neurological disability
  • whats the difference
  • MRI scanning evidence
  • Remember we are insuring the person not the brain
    scan
  • Silent infarcts?

43
Vermeer et al Prevalence Risk Factors of
Silent Brain Infarcts in the Population Based
Rotterdam Scan Study. Stroke January 2002,
21-25.
44
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45
Permanent Neurological Damage?
  • Confusing term..
  • Do we mean permanent neurological disability
  • whats the difference
  • MRI scanning evidence
  • Remember we are insuring the person not the brain
    scan
  • Silent infarct - do not meet claim criteria

46
Stroke definitions - problems
  • Should SAH be separately insured?
  • Is TIA with a small MRI lesion a stroke?
  • How long and by what criteria should deficit
    persist?
  • The issue of age-related silent infarcts
    resembles silent myocardial ischaemia and should
    be handled similarly
  • Brain infarction after brain compression is not
    stroke

47
Head Injury
  • Implications for TPD and stroke claim
  • Outcome after head injury?
  • GCS/AIS Score
  • Subarachnoid haemorrhage
  • Minor head injuries/post concussional syndrome
  • Post traumatic stress disorder

48
Head Injury Scoring
  • GCS (Glasgow Coma Score)
  • AIS (Abbreviated Injury Scale)
  • AIS 1-2 short period of unconsciousness or
    linear skull fracture
  • AIS 3 complex skull fracture or cerebral
    contusion
  • AIS 4 prolonged unconsciousness or intracranial
    haemorrhage
  • AIS 5 unconsciousness gt 24 hours, diffuse brain
    lesions, or severe mass effect

49
Outcome after Head Injury
Masson F et al. Disability and handicap 5 years
after head injury a population-based study.
Journal of Clinical Epidemiology 1997 50 595-601

50
Disability rates in patientswith AIS Scores 4
and 5
Masson F et al. Disability and handicap 5 years
after head injury a population-based study.
Journal of Clinical Epidemiology 1997 50
595-601
51
5 year death rate followinghead injury
Masson F et al. Disability and handicap 5 years
after head injury a population-based study.
Journal of Clinical Epidemiology 1997 50
595-601
52
Epidural Haematoma
53
Brain Haemorrhage after backwards fall
54
Parkinsons Disease
55
Parkinsons Disease
  • No test available
  • Diagnosis is made on the basis of clinical
    evaluation
  • Claim criteria
  • Confirmation by a Consultant Neurologist of a
    definite diagnosis of Parkinsons Disease (before
    age ?).


    Parkinsons Disease secondary to alcohol or drug
    misuse is not covered.
  • Implications for TPD - what is occupation?

56
Common additional problems in PD
  • Loss of manual dexterity
  • Depression, hallucinations and dementia
  • Falls
  • Autonomic Nervous System dysfunction
  • Dyskinesias

57
The Times Wednesday 17 April
58
Related conditions
  • Lewy body dementia
  • Progressive pseudobulbar palsy
  • Cortico-basal degeneration
  • Apractic syndromes
  • Picks disease
  • Other dementias with extrapyramidal signs

59
Things to be sure of
  • History of the illness
  • When was it suspected, and when diagnosed?
  • What is the evidence?
  • How bad is it? (for TPD, IP)
  • Who is giving the information?
  • Is there a conflict of interest?

60
Implications
  • Seek clarity
  • Confirm the diagnosis, against the insured
    definition
  • Consider non-disclosure as an issue
  • Consider the quality of the evidence
  • Be fair and consistent

61
Neurological Disorders
Michael Swash Royal London Hospital
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