TABLE OF CONTENTS Feb 2013 - 0 comments

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The population is aging, fuelling the debate over the reliability of senior motorists. The situation has revealed looming challenges that North American auto insurers need to address with regard to underwriting, rating and claims management of drivers who have pre-existing cognitive impairments.

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By: Scott Knight and Konstantine Zakzanis

A "74-year-old driver plowed his SUV through a crowded intersection and into a group of people waiting for the bus in Montreal... killing two bystanders and sending pedestrians hurtling through the air 'like bowling pins'"... an "87-year-old man drove his car through a crossed street market in Santa Monica, California, killing 10 people..."

News stories like these seem to be occurring more frequently, sparking renewed debate over whether or not North America's aging population poses a public-health hazard on the roads. Transportation statistics, based on a variety of reports, indicate that seniors, those aged 65 and older, have a higher annual fatality rate than younger drivers and, measured by distance driven, these older drivers are involved in accidents out of proportion to their numbers.

The debate over the reliability of aging motorists usually includes discussion about the diseases and other health issues that are often part of the aging process. In particular, dementia is cited as a growing concern.

In an insurance role, whether it be as an underwriter or adjuster, understanding dementia/ cognitive impairments and how to assist clients who may be suffering from dementia is likely to become more pertinent.

For the North American auto insurance industry, there are looming challenges to be addressed on the underwriting, rating and claims management of drivers with pre-existing cognitive impairments. However, there is a lack of data available to insurers from which to base rating and underwriting decisions.

Without family doctors and health care professionals proactively and reliably documenting their own files, there is insufficient information on which claim personnel may form decisions. Notwithstanding the missed opportunities with respect to rating and underwriting, this lack of information on a single claim may cost an insurer upwards of $1 million to $2 million on an alleged catastrophic injury claim.


The population continues to age. By 2011, the oldest baby boomers, those born in 1946, had reached age 65 and the proportion of people that age and older had started to increase rapidly. This shift in the population size of the elderly will have far-reaching effects, especially on the health care system.

A major issue will be the incidence of dementia: more than 50% of the residents in nursing homes are affected by dementia; one in every 13 seniors over the age of 65 has Alzheimer's disease, the most common form of dementia; and one-third of seniors have some form of dementia by age 85, while more than half do by age 95.

A joint report released last April by the World Health Organization and Alzheimer's Disease International, Dementia: A Public Health Priority, indicates a global time bomb that needs to be addressed statistically:

• there are in excess of 10 million cases of dementia globally;

• there are 7.7 million new cases of dementia per year globally;

• there are 5.4 million people in the United States with Alzheimer's disease, 2.3 million with other dementias and almost 11 million with other cognitive impairment disorders; and

• there are 7.9 million licensed drivers over the age of 80 in the U.S.

The prevalence of cognitive impairment disorders is expected to increase by 50% in the next 20 years with the "greying" of the U.S. population. Here at home, findings of a Canadian Psychiatric Association research paper from 2004, Driving and Dementia in Ontario: A Quantitative Assessment of the Problem, include the following:

• the number of drivers 65 years or older will increase from slightly less than 500,000 in 1986 to almost 2.5 million in 2028;

• there will be almost 100,000 drivers with dementia in Ontario by 2028;

• most drivers with dementia will continue to drive as the disease progresses, increasing the likelihood it will eventually affect their driving ability; and

• The Ministry of Transportation does not require any remedial driver testing until age 80, and testing does not screen for dementia deficits related to driving or screen any population exhibiting possible deficits under the age of 80.


The findings also recommend the risks associated with the dramatically increasing number of drivers with dementia demand a psychometrically sensitive and efficient screening procedure. An effective approach in guiding decision-making related to dementia is the use of neuropsychological testing, which offers an understanding of the progressive nature of dementia and highlights the importance of early intervention.

In North America, the prevalence of dementia alone in the +65 years population group (excluding cognitively impaired not dementia, or CIND) approaches 25%. Research indicates that within the older than 65 age group, the annualized incidence rate of undiagnosed cognitive impairment is 2%.

The Alzheimer Society cites research documenting early-onset dementia occurring as early as 45 years of age, and when considered with advancing research on concussions/post concussive syndrome, there are serious implications with which to contend. 

Understanding Dementia

Dementia is an acquired condition of intellectual impairment produced by brain dysfunction. It can be defined as an acquired persistent impairment of intellectual function that affects at least three of the following areas of mental activity: language; memory; visuospatial skills; emotion/personality; and cognition (i.e. abstraction, calculation, judgment, executive function, etc.)

Depending on the type of dementia, cognitive deficits in the early stages may vary. However, regardless of the specific type, it is important to note that all are progressive.

A prerequisite for driving is the integration of high-level cognitive functions with perception and motor function. Aging, per se, does not necessarily impair driving or increase the crash risk. But medical conditions, such as cognitive impairment and dementia, become more prevalent with advancing age and may contribute to poor driving and an increased crash risk.

The extent to which driving skills are impaired depends on the cause of dementia, disease severity, other co-morbidities and individual compensation strategies. Dementia often remains

undiagnosed and, therefore, general practitioners (GPs) can find themselves in the difficult situation to disclose a suspicion about cognitive impairment and queries about medical fitness to drive, at the same time. In addition, the literature suggests that cognitive screening tests, most commonly used by GPs, have a limited role in judging whether or not an older person remains fit to drive.

Early Identification and Intervention

Early identification is the best way to prevent harm and reduce risk (literature further suggests that pharmacological strategies, namely use of medications, can slow the progression of dementia). Early intervention also helps to ensure the individual is brought to the attention of the appropriate health care practitioner as soon as possible so that he/she may immediately begin appropriate treatment.

Dementia is identified by neuropsychological testing, which evaluates/ tests disturbances in the various areas of mental activity. The testing is a specialized sub-discipline of psychology that focuses on the relationship between brain and behaviour by way of formal standardized paper and pencil measures.

Unfortunately, full neuropsychological assessments are not only very expensive (these cost an estimated $3,500 to $6,000) and time-consuming, limitations exist on accessibility and language barriers of assessors within a multi-cultural context, meaning this cannot be considered a practical solution.

Looking to clear these obstacles, Konstantine Zakzanis, Ph.D., a professor at the University of Toronto, has developed a 15-minute, patent-pending test sensitive to cognitive disorder secondary to numerous disease states or injury. These include the early stages of Alzheimer's disease and other dementia syndromes; post-concussive syndrome; attention deficit disorder; or other disease processes affecting brain function. Dr. Zakzanis's test, called Brainscreen, demedicalizes the screening process. The screen, costing about $25 apiece, can be completed without the aid of an administrator on various mobile and personal computing devices.


Rafts of research confirm the correlation between cognitive function and driving, creating an opportunity for insurers to deploy a cognitive screening tool at the time of policy issuance. If the test in question does not require special training or administration, costs could be lowered since an applicant could access the tool in the home, direct via the underwriter or via the broker/agent network. All results and data could be instantaneously delivered to the insurer and its approved designates.

Insurers could use the test on suspected traumatic brain injury claims and validate a client's cognitive decline relative to his or her scores at the time of policy issuance - this would be similar to baseline scoring as might be employed for concussion management programs. Immediately following submission of a claim, a case manager or adjuster could "administer" the test to validate or compare any cognitive deficits from policy issuance to claim.

Even without a pre-test, administering the screen following the submission of a claim will help validate any cognitive deficits relative to the normative population as well as assist in determining whether or not to employ full neuropsychological testing and, possibly, identifying what specific test batteries ought to be used in the assessment.

A report published in the September 2012 issue of the New England Journal of Medicine indicated a proactive reporting system associated with fitness to drive, with study authors estimating annual savings to the Province of Ontario of approximately $7 million through crash prevention (the figure does not take into account the additional savings for auto insurers). For their part, consumers would be better served with rating and underwriting specific to their own unique risk factors.

With the large aging cohort moving forward and research expanding on cognitive awareness/function impacted by trauma and pharmacological contraindication, serious significant ramifications abound. The advantages to be had as a result of cost-effective and accessible early screening - not only from the public safety perspective, but also from that of an insurer considering underwriting and claims - outweigh any disadvantages.

Over the past seven years, there has been ongoing research that directly links cognitive function to driving abilities across all age groups. Industry stakeholders should be working together to champion a policy of cognitive screening for the benefit of their customers and society.

Society will benefit through access to a health care tool that ought to form part of every annual check-up, while insurers and consumers benefit through more exacting underwriting and rating. This will be reflected in more accurate premium calculations at policy inception and renewal, and help to drive down injury assessment costs on claims.


Konstantine Zakzanis, Associate Professor, Department of Psychology, University of Toronto
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Scott Knight, Executive Director, The Hemisphere Centre for Mental Health & Wellness
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