Falls: Significance in Life Expectancy Underwriting

As our population ages, the significance and frequency of falls increases. This affects life expectancy as well as morbidity and mortality. It is important to remember this both when evaluating prospective clients in life underwriting and when considering life settlements. In order to begin to understand the significance of falls in the elderly, it is always helpful to start with a definition. What exactly constitutes a fall? The World Health Organization defines a fall as an ‘event where a person comes to result inadvertently on the ground or other lower level’. 

Falls in the elderly population are a common reason for emergency room visits and hospital admissions. According to the CDC, about 36 million falls are reported by older adults each year. The CDC also estimates that each year approximately 50 billion dollars is spent on medical costs related to older adult falls. In 2020, 27.6% of adults over age 65 reported a fall in the preceding year. It is reported that 60% of individuals with a fall in the preceding year will have a subsequent fall. Falls are underreported as some result in minor injury and no treatment is sought. This makes sense as someone who stumbles and gently goes to the ground without injury is more likely to brush it off and not report it to their physician. Previous studies of community-dwelling older individuals found 5-10% of falls resulted in fractures, head trauma, or major lacerations. Falls result in approximately 60% of all non-fatal injuries leading to emergency room visits in people over the age of 65. Fall related injuries are associated with significant morbidity, change in functional status and increased need for nursing home placement. Complications resulting from falls are the leading cause of death from injury in individuals over 65. 

It is possible to evaluate medical records and medical history for risk factors that may lead to increased frequency of falls. UpToDate reports the following as significant risk factors for falls: prior history of fall, age, lower extremity weakness, female sex, cognitive impairment, balance problems, psychotropic drug use, arthritis, history of stroke, dizziness, orthostatic hypotension, and anemia. Other studies include sensorineural problems such as neuropathy and intermittent vertigo as well. Clinicians and geriatricians frequently do in office assessments for fall risk. Frequently, the tool used for this is Up and Go testing. This involves having an individual stand from a chair, walk 10 feet and return to the chair and sit. This test is timed. Less than ten seconds is considered normal. Elderly individuals who can complete this in under 20 seconds are considered to have good mobility and can likely walk alone without an aid. Greater than 30 seconds indicates a fall risk. 

When evaluating falls for underwriting it is important to remember that not all falls are equal in significance. The environment of the fall and the conditions leading to the fall are important considerations. Indoor falls at home are associated with indicators of poor health, disability and inactive lifestyle.  

Outdoor falls are associated with an active lifestyle and better than average health. As can be imagined, a trip and fall while jogging outside is a different situation from a functional standpoint than a fall while simply trying to get out of bed.  

The ability to get up following a fall is an important consideration as well. Only one half of older individuals who fall are able to get up independently. This can result in “Long Lie” which can cause these individuals to suffer lasting declines in their activities of daily living. The injuries resulting from falls are one of the most important considerations for assessing mortality and morbidity risk. The highest associated mortality from a fall Is associated with those resulting in intracranial injuries and hip fractures. 

Various studies have attempted to look at the short-term mortality risk following a fall. One study found the mortality risk after a fall to be 9.6% in the first 30 days and 33% after a period of one year. Another study found the one-year cumulative mortality following a fall with a severe fracture to be 25.2%. The cumulative mortality for individuals with a fall without a severe fracture was found to be 4%. One highly regarded reinsurance manual recommends life insurance declination for individuals with greater than or equal to three falls in one year, a fall resulting in long lie, or a history of recurrent falls with multiple fall risk factors. 

In conclusion, falls are associated with an increased risk of morbidity and mortality. It is important to remember that not all falls are created equal. Location and type of fall are important when assessing risk. An elderly person out walking accidentally knocked over by a dog is different than a person falling at home after tripping over their shoes. The previous person is likely active and statistically more likely healthy, and the chance of subsequent falls is likely less. Second, the injuries from the fall are important to consider as well. Previous hip fractures from a fall or intracranial injuries indicate likely significant morbidity and risk for future significant falls. Last, significant fall risk – even without a history of falls – warrants debits and a higher mortality risk assessment in life expectancy underwriting. 

Scott McClure is Medical Director at Fasano Underwriting