A fresh approach: the life industry is looking at ways to improve the assessment of mortality risk in elderly applicants.

Today the most common question asked by insurers about elderly applicants

is not whether the industry should begin screening for functional impairments, but how we can screen most efficiently and what screening tools are most effective.

At issue is how to develop a new set of information in addition to that delivered by traditional underwriting that can improve how the industry assesses mortality risk in elderly applicants.

Interestingly, traditional underwriting requirements do retain their protective value and, in some arenas, have even greater protective value among elderly applicants. This is certainly true for requirements such as attending physician statements where the greater likelihood of disease in older compared to younger applicants enhances the statements' protective value. It is also true for exercise stress tests, which not only detect cardiac and pulmonary disease, but also measure exercise capacity, one of the most important factors predicting subsequent mortality among elderly individuals.

Exercise capacity is just one part of the puzzle in gauging a person's overall well-being--physical, mental and social--that becomes a crucial assessment for many elderly applicants. Where do applicants fall between two key terms, "frail" and "robust"? Clinicians use the term "frail" to describe persons at increased risk of dying or suffering complications from an illness or injury, while those likely to successfully recover are termed "robust."

Although the medical community has had difficulty agreeing on more precise definitions for these two opposing assessments, frail and robust, accepted markers of frailty include impairments in physical and cognitive functioning. The inability to perform basic activities of daily living without help like dressing, eating and bathing or the inability to perform more advanced activities is associated with substantial excess mortality.

Unfortunately, it is unlikely that these impairments will be identified without specialized tests of functional ability. Many insurers are assessing frailty by using questionnaires to simply ask proposed insureds whether they have any memory impairments or physical limitations. Although these likely provide some protective value, their usefulness depends on the applicant's candor. Underwriting tools developed specifically for elderly applicants will vary from company to company and depend on each company's target market and desired level of mortality risk. However, there are a few widely applicable guidelines:

* Given that the elderly population is more heterogeneous than the population consisting of the central ages, underwriting--by virtue of its ability to determine differences in health and functional status--can be of even greater protective value in the elderly than in the central ages, provided the correct underwriting tools are used.

* Traditional underwriting remains important in the elderly. Underwriting must continue to effectively identify and assess the risks posed by diseases and impairments already present at the time of application. Also, underwriting should assess the risk for future disease based on risk factor analysis that differs from accepted analysis for the central ages. For example, although being overweight is a risk factor for morbidity and mortality both in central and older ages, in the elderly moderate obesity is associated with relatively less excess mortality, while being underweight is associated with relatively greater mortality.

* Thorough traditional underwriting will identify many elderly individuals in whom further screening for cognitive and functional impairments will be unnecessary. Traditional underwriting will identify some elderly applicants who are so ill that further evaluation will not be necessary to arrive at an accurate appraisal of risk.

* Thorough traditional underwriting, perhaps supplemented by telephone interviews or questionnaires tailored for the elderly and incorporating questions on functional abilities, will likely identify other individuals who are obviously so healthy and who are functioning at such a high level that further evaluation offers little additional value.

* Finally, there likely will be a middle ground of elderly applicants whose status has not been sufficiently determined by traditional underwriting tools. In such cases, the risk will be clarified by supplementing traditional underwriting tools with new screening tools designed to detect functional impairments.

Frailty is a powerful and independent factor for predicting excess mortality in applicants 75 years old and above. Supplementing traditional underwriting with frailty screens can clarify the mortality profile of this age group, differentiate its risk and help price policies appropriately.

Dr. Martin Engman, a Best's Review columnist, is vice president, research, and senior medical director for ING Re's Individual Life and Health Operation based in Denver. He can be reached at [e-mail].