For Financial Adviser use only. Not approved for use with customers.
Understanding underwriting
A guide to medical conditions and
the underwriting process
Retirement
Retirement
Retirement
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Investments
Insurance
Health
Investments
Insurance
Health
Investments
Insurance
Health
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Contents
3Welcome
4
What is underwriting?
5
The proposal form
6
Medical evidence
8Decisions
10 Medical conditions guide
26 Underwriting factors:
28 •Medical – the digestive system
33 •Medical - the respiratory system
37 •Medical – the endocrine system
41 •Medical – the central nervous system
45 •Medical – mental illness
47 •Medical – the musculoskeletal system
53 •Medical – tumours
57 •Build
59 •Smoking
60 •Alcohol
61 •Drugs
62 •Residence and travel
63 •Financial underwriting
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Welcome
For some advisers, underwriting is something of a dark art: a process into which some proposals go and, sometime
later, policies appear – or not, as the case may be.
Traditionally, the underwriting process began with the proposal for cover and the questions within it. In recent
years, though, we’ve seen alternatives emerge to having all the questions contained in a lengthy initial application
form. With tele-interviewing and tele-underwriting, for instance, some or all of the underwriting questions are
handled during a telephone conversation.
Shifts like this have sped up the initial application process. But they can cause problems further down the line. If
you or your client weren’t aware that further evidence would be needed, for example, getting covered can take a
lot longer than expected. Frustration abounds.
That’s where this guide can help. It’s not supposed to teach you how to be an underwriter. But it should help you
better understand:
l
the questions we ask on a proposal and why we want the answer
l
your customers’ disclosures and what they’re likely to mean in terms of their application(s)
l
the types of additional medical evidence we ask for and why
l
the decisions we make and how we can help you to explain these to your customers.
By improving your understanding of these areas, you’ll be able to help your client disclose the correct information
and advise them if their cover will take a little longer to come through.
Michael Whyte
Aviva UK Life
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What is underwriting?
All proposals for life insurance and critical illness cover go
through a risk assessment process called underwriting. The
purpose of this is to determine:
l
a person’s eligibility for the cover they are seeking
l
the premium they should pay.
The application process allows us to gather all the information
we need to underwrite your client. We use their age, personal
circumstances and smoking status to determine their basic
premium – but we also consider a number of other factors,
which we’ll explain later in this guide.
While all Protection applicants are underwritten most will be
accepted from their application alone. But by using expertly
trained underwriters and cutting edge technology to assess
applications, we ensure that even more complex cases are
handled as quickly as possible.
The technology we use to speed up
decisions
We use ‘intelligent underwriting systems’ to speed up the
underwriting process. These are what you use when you submit
an application on aviva.co.uk/adviser. They use hard-coded
rules, created by us, to generate underwriting decisions at the
time you submit an application. The systems only ask questions
that are relevant to the details you have entered. And, depending
on the answers provided, they can ask further questions when
we need more information to give a decision. These systems help
us increase acceptance rates at the point of application.
An extra benefit of using these systems is that they can help
reduce the amount of additional evidence we need. And
because less human intervention is needed, it can lower
processing costs and improve the consistency of our decisions.
They also generate some useful management information,
which helps us to refine our question sets further.
How do you become an underwriter?
Most underwriters are trained apprentice-fashion because the
role and responsibilities call for significant experience as well as
technical knowledge. A skilled underwriter combines a thorough
knowledge of medical conditions and risk, and it can take many
years to achieve Aviva’s full underwriting authority.
At Aviva we have an underwriting academy, which all our
underwriters have to go through. The Chartered Insurance
Institute (CII) also offers a professional qualification, the
Diploma in Life and Disability Underwriting, which many Aviva
underwriters hold or are studying towards.
4 Understanding underwriting
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The Proposal Form
The proposal completed by the customer/adviser forms the basis
of the insurance contract between the insurer and the insured
and includes questions about build, personal and family medical
history, occupation and pastimes.
Past and present medical history – where requested it is
essential to provide dates of treatment, frequency of symptoms and
whether investigations or consultations are ongoing/outstanding.
Height and weight – if a proposer falls outside our standard
limits, determined by their Body mass Index (BMI) then we will
increase their premium.
Inherited Conditions – the proposal explains the details of
inherited conditions and family history that the customer needs
to tell us about.
Smoking – as well as determining whether or not an applicant
is charged smoker rates, very high consumption may result in
a further increase in premium. Our definition of a non-smoker
is someone who has not used tobacco products – cigarettes,
cigars, pipe tobacco, chewing tobacco or the use of nicotine
replacement products (such as e-cigarettes) – in the 12 months
prior to their proposal.
Occupation – very few occupations will result in a premium
increase for life and Critical Illness. However the nature of duties
can affect acceptability for Premium Protection or the definition
of disability under Total Permanent Disablement (if Critical Illness
is selected). Occupation is important for Income Protection for
both premium setting and underwriting. The more accurate and
precise you can be in providing details of the occupation, and
where requested the industry involved, the easier it will be to
assess.
Recreational activities – a number of activities can carry
elements of additional risk depending on the standard and
frequency with which they are practiced. Sometimes extra
questions are needed to help us understand the extent of that risk.
Overseas travel – some overseas countries represent an
increased risk due to health. Full details of any recent travel
(within last 5 years) or residence outside of the European Union,
North America, Australia, and New Zealand are needed together
with details of any plans or expectations the customer may
have of travelling outside of these areas within the next 2 years.
Normal holiday travel of less than 30 days can be discounted.
More details about the above are in “Underwriting Factors”
Alcohol consumption – we do ask about drinking habits but
please note moderate social drinking will not affect premiums.
Recreational drug use – we need to know about
“recreational” drug use in the last 5 years. Recreational drugs
include, but are not limited to, cocaine, heroin, amphetamines
and solvents.
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What medical evidence
could be requested?
When we are unable to make a decision based on the
information provided on the proposal form, additional medical
evidence can be requested to assist the underwriter in their
decision making.
Mini screening
Just how much evidence will depend upon the information
provided by the customer as part of their initial application.
Blood pressure, height and weight measurements and a urine
test are carried out. We may also require an HIV test or cotinine
test to confirm the customer’s smoking status and is simple to
perform and requires a sample of saliva. If one of these tests is
required you and your customer will be informed.
Sometimes medical evidence may be automatically required due
to the customer’s age or the level of cover they are seeking (see
Section 7: Automatic Medical Underwriting Requirements).
These are simple screenings carried out by a nurse, usually in
the person’s own home at a time convenient to the customer.
The additional medical evidence an underwriter may call
for include:
General Practitioner’s (GP’s) report
These are obtained from a person’s own doctor. In order to
proceed a customer gives us permission to approach their
doctor (under the Access to Medical Reports Act) for a report
which customers can elect to view before the report is sent
to us. The report is in a standard industry format and the
information that the doctor will provide to the insurance
company will include:
a) Details of the customer’s current state of health and any
treatment they are currently taking.
b) Details of relevant past medical history (including any
investigations or tests, which have taken place at any
surgery, clinic or hospital).
c) Details of any medical investigations, referrals or treatment
that is awaited.
d) Details of any medical conditions known to occur within the
family.
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Nurse tele-interview
Electrocardiograph (ECG)
Occasionally we will ask a nurse to telephone the customer to ask
some further questions about something they have disclosed on the
proposal. This phone call doesn’t usually last more than 10 minutes
and will be carried out at a time convenient to the customer.
An ECG is an electrical recording of the heart. It enables doctors
to understand far more about the condition of the heart muscle
and the rate and rhythm of the heart.
Medical examination
This is usually carried out by an independent examiner, selected
and arranged for us by a third party provider of medical services.
Such examinations tend to be called for when the cover amount
is large, the customer is of above average age, or where the
customer may have a medical condition about which we need
more information. The examination is usually in two parts.
The first includes a detailed questioning by the doctor of the
applicant’s medical and family history, drinking and smoking
habits. The second is a full examination including, heart, chest,
blood pressure and urinalysis. If an HIV test is required, this will
be performed at the same time from either a sample of saliva
or blood.
HIV tests
We use saliva and blood testing. The nurse or doctor sends the
samples directly to the laboratory. The results are sent to Aviva.
In the unlikely event that a positive result occurs, this is sent
directly to the Chief Medical Adviser who deals personally with
the situation. The proposer will be told the result of an HIV test.
Microscopic urinalysis (MSU)
The microscopic urinalysis is the study of the urine under the
microscope to identify any cells, bacteria and clumps of cells or
debris called casts.
Fasting lipids estimation (FLP)
A blood test which measures the key blood fats that can
indicate an increased risk of heart disease.
Full blood profile (FBP)
Full Blood Profile (Haematology, Biochemistry including Renal
and Liver Function and Fasting Lipids Estimation).
Prostate specific antigen
screening (PSA)
A blood screening test which can detect presence of an
asymptomatic cancer of the prostate.
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Underwriting Decisions
The final decision on a protection application will be one of the
following. Different decisions may apply to different benefits.
Standard rates
The application is accepted as originally quoted. This will be the
case for the majority of applicants.
So a life whose risk of dying is considered to be twice that of
a standard risk will be loaded at 200% (or plus 100%). These
loadings will normally result in a straightforward increase in the
premium. Thus this loading will result in the premium increasing
by 100%. For some policies this loading will vary according
to age.
Temporary loadings
Exclusions
An exclusion means that if the insured event occurs in a specific
circumstance then the cover amount will not be paid. They are
very rarely applied in life assurance but are more common in
critical illness and income protection.
For instance a recurring back problem may need to have an
exclusion applied for any claims related to the back.
Permanent loadings
These are used when the additional risk is thought to continue
for the duration of the policy. The loading applied is usually by
the numerical rating system which is calculated as a factor of
the basic mortality risk of 100% - usually in 25% steps.
Some increased risks are assessed as being constant or higher
in the first few years. Here a cash extra may be charged and
applied temporarily during the period of high risk. This extra is
calculated as a factor of the cover amount and usually expressed
as a ‘per mille’ loading. Thus a one per mille loading will add an
extra £1 per £1000 cover amount per year. For a cover amount
of £200,000 this would lead to an extra £16.67 being charged
per month(£200,000 x 1%)/12.
Combinations of extra mortality loadings and cash extras may
be charged.
Examples
Reason
Loading
Detail
Medical
Male, aged 51, Mild heart attack 2 years ago. Now fit
and well
Plus 150% Extra Mortality (EM) = plus 9 years
to age
Medical
Female, History of invasive breast cancer. Confined to
axilliary lymph nodes only. Treatment ceased 4 years ago.
Temporary cash extra of 15 per mille for 6
years. Permanent cash extra of 12 per mille.
Build
Female aged 36. 5 feet 6 inches. 15 stone 12 lbs
Plus 50%EM = plus 4 years to age
Lifestyle
Aged 38. Heavy smoker 40 cigarettes per day
Plus 50%EM = plus 4 years to age
Occupation
Scaffolder. Regularly working at heights > 15m
2 per mille
Pursuit
Amateur mountaineering. Heights up to 7000m (Alps)
several times a year.
4 per mille
Decline
Defer
If the risk is too great then an application will be refused.
If the risk is too high but may improve then an application may
be deferred for a specific period. This means that after this time
has elapsed then a new proposal could be considered. This
would be subject to underwriting. Also used when an individual
is undergoing or awaiting tests or investigations. Without the
results of these it is not possible to make a full assessment.
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A Guide to Medical Conditions
We have included some of the most common medical
conditions we encounter and have incorporated:
l
a brief explanation of each condition
l
the usual evidence needed to underwrite
l
the most likely underwriting decision
l
case studies.
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Medical Condition Guide –
Rating Key
LIFE
MILD
MODERATE
SEVERE
up to 75% EXTRA MORTALITY
100 – 150% EXTRA MORTALITY
175% and over EXTRA MORTALITY
CRITICAL ILLNESS & INCOME PROTECTION
MILD
up to 50% EXTRA MORBIDITY
MODERATE
75 - 100% EXTRA MORBIDITY
SEVERE
125% and over EXTRA MORBIDITY
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Angina
What is the condition?
Case study
Chest pain associated with coronary heart disease (narrowing
of the blood vessels that carry blood to the heart). This leads to
inadequate blood flow to the heart muscle.
Client (aged 56) disclosed angina and a copy of his medical
records revealed:
What information do we need?
Stable angina diagnosed three years ago, occasional symptoms
only, no other risk factors.
A GP report.
Underwriting decision: +150 for life. CI, income protection
and TPD declined.
Please note:
Further reading: British Heart Foundation www.bhf.org.uk
lOur
decision will depend on the applicant’s age, frequency
and severity of symptoms, the extent of the heart disease
(for example, how many vessels are affected, if known), and
the presence of any other risk factors.
lWe
can’t offer any type of cover if the applicant was under
40 when the condition started.
lIf
angina was diagnosed in the last six months, we’ll
postpone cover.
lWe
can’t offer any cover if the applicant has both angina
and diabetes.
lWe
can’t offer critical illness cover for an applicant
with angina.
Decision guide
CI
IP
TPD
Severity
Life
Stable,
infrequent/
minor
symptoms
Moderate
Decline
Decline
Decline
Frequent
symptoms
Severe
Decline
Decline
Decline
Severe
Decline
Decline
Decline
Decline
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Arthritis
What is the condition?
A disease affecting one or more components of a joint (cartilage,
lining, bone), usually with accompanying inflammation. Arthritis
can affect people of all ages, and there are various different types.
The most common forms of arthritis are:
lOsteoarthritis
– the most common type of arthritis in the
UK, usually developing in those aged 50+. It’s caused by
erosion of the cartilage resulting in bone surfaces
rubbing together.
lRheumatoid
arthritis – a condition in which the body’s
immune system targets the joints, leading to pain and
swelling. Women are three times more likely to be affected
than men. Sufferers can also develop problems with other
tissues and organs in their body.
lAnkylosing
spondylitis – an inflammatory disorder of the spine.
What information do we need?
l
Type of arthritis and joints involved.
l
Frequency and severity of symptoms.
l
Time off work/impact on daily activities.
lTreatment.
If we don’t get enough information from the application, we
may request a nurse tele-interview. Or, if the condition appears
more severe, we may need a GP report.
Please note:
Decision guide
Severity
Life
CI
IP
TPD
Minimal
pain/
swelling,
occasional
treatment
OR
Exclusion
Exclusion
Exclusion
Moderate
disease
activity,
frequent or
continuous
treatment
Mild/
Moderate
Exclusion
Decline
Decline
Chronic
active
disease
with
restricted
activities of
daily living
Moderate/
severe
Decline
Decline
Decline
Case study:
Client disclosed rheumatoid arthritis with slight deformity and
limitation of movement in the affected joints (hands/knees/feet).
Continuous anti-inflammatory drug therapy required.
Underwriting decision: +75 for life, CI OR but arthritis
excluded, IP and TPD declined.
Further reading: Arthritis Research UK,
http://www.arthritisresearchuk.org/
Rheumatoid arthritis is a named condition under our critical
illness cover, so we’re likely to apply an exclusion.
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Asthma
What is the condition?
Case study:
A disorder of the airways typified by recurrent episodes of
wheezing, shortness of breath, chest tightness and cough.
Client disclosed asthma with symptoms in the last two years but
no hospital admissions, oral steroid treatment or time off work.
Underwriting decision: OR for all benefits, no medical
evidence required.
What information do we need?
Further Reading: Asthma UK, www.asthma.org.uk
l
Frequency and severity of symptoms.
l
Dates of any hospital admissions.
l
Time off work/impact on daily activities.
lTreatment,
including the prescription of steroid tablets (if so,
how often and latest date).
If we don’t get enough information from the application, we
may request a nurse tele-interview. Or, if the condition appears
more severe, we may need a GP report.
Please note:
Heavy smokers may receive a rating even if their symptoms
appear relatively mild.
Decision guide
Severity
CI
Life
IP
TPD
Infrequent/
minor
symptoms
OR
OR
OR
OR
Regular
symptoms,
higher dose
medication,
time off
work
Mild/
Moderate
Mild/
Moderate
Moderate/
severe
Mild to
Decline
Frequent/
continuous
symptoms,
poor
response to
treatment
Severe/
Decline
Decline
Decline
Decline
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Back pain
What is the condition?
Case study:
Pain/discomfort in the spinal column or supporting muscles,
ligaments and tendons.
Client disclosed back pain with minor symptoms and some
restriction in activities, not awaiting any hospital investigations.
What information do we need?
Underwriting decision: OR for life and CI, IP and TPD
accepted with spine exclusion.
l
Cause, if any.
l
Frequency and severity of symptoms.
l
Date of last episode.
l
Time off work/impact on daily activities.
l
Treatment and details of any surgery.
lOccupation.
lComplications
(eg neurological symptoms, bowel/bladder
impairment which may occur as a result of spinal nerve root
compression).
If we don’t get enough information from the application, we
may request a nurse tele-interview.
Decision guide
Severity
CI
Life
IP
TPD
More than
4 years
since last
episode
OR
OR
OR/spine
exclusion
OR/Spine
exclusion
Current
mild/
moderate
symptoms
OR
OR
Spine
exclusion/
Decline
Spine
exclusion/
Decline
Severe,
disabling
back pain
Mild
OR
Decline
Decline
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Blood pressure raised
(Hypertension)
What is the condition?
A sustained increase in blood pressure. Blood pressure is the
force of blood pushing against the walls of arteries as it flows
through them. Arteries are the blood vessels that carry blood
from the heart to the body’s tissues. High blood pressure
means the heart has to work harder to pump blood around the
body, and this increases the risk of developing heart disease or
suffering a stroke. High blood pressure is a common condition
which often goes undetected as it usually causes no symptoms.
What information do we need?
l
Date of diagnosis.
l
Last blood pressure reading and when it was taken.
lTreatment.
lOther
cardiovascular risk factors (height/weight, family
history, raised cholesterol, smoking).
If we don’t get enough information from the application, we
may request a nurse tele-interview. Or, if the condition appears
more severe, we may need a GP report.
Decision guide
Severity
CI
Life
IP
TPD
Well
controlled,
no other
risk factors
OR
OR
OR
OR
Suboptimal
control,
high dose/
Multiple
treatments
Mild/
Moderate
Mild/
Moderate
Mild/
Moderate
Mild/
Moderate
Hospital
treatment,
poor
response,
multiple risk
factors
Severe
Decline
Decline
Decline
Case study:
Client disclosed raised blood pressure diagnosed more than a
year ago, takes one tablet a day, no change in treatment in the
last six months, last reading six months ago and GP confirmed it
was well controlled, no other risk factors.
Underwriting decision: OR for all benefits, no medical
evidence required (if all the required details can be obtained
from the application/client phone call).
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Cancer
What is the condition?
Case study:
A condition where cells in a specific part of the body grow and
multiply uncontrollably. The cancerous cells can invade and
destroy surrounding healthy tissue and spread (metastasise) to
other areas. Malignant tumours are cancerous; benign tumours
are not.
Client disclosed breast cancer (grade two) diagnosed four years
ago – a copy of her medical records revealed:
Breast cancer diagnosed and treated completed just over
four years ago, grade two, stage two, size of tumour 2.5cm,
oestrogen receptor positive, no recurrence or other risk factors
Underwriting decision: a temporary monetary extra of £10
per mille for 4 years for life cover. CI, IP and TPD declined.
What information do we need?
A GP report.
Please note:
lOur
decision will depend on many factors, including the
location of the cancer, date of diagnosis, the histology,
grade (degree of cell abnormality), staging (size of the
tumour, whether it has spread), and when treatment
was completed.
lWe
may decline critical illness cover or, in some cases, we
may offer it with an exclusion.
Decision guide
Severity
Life
OR/rating/
Depends
on multiple Defer/
Decline
factors
including
location,
severity,
how long in
remission,
etc.
CI
Decline or
Exclude
IP
OR/
Rating/
Decline
TPD
OR/
Rating/
Decline
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Cholesterol raised
(Hypercholesterolaemia)
What is the condition?
Case study:
Cholesterol is a fatty substance which circulates in the blood.
When the amount of cholesterol is raised above an acceptable
level based on age and gender, it increases the risk of heart
disease and stroke as fatty deposits form inside the blood
vessels and hinder the flow of blood. Factors most likely to
contribute to high cholesterol are a diet high in saturated fat,
smoking, lack of physical activity and high alcohol intake.
Client (age 50) disclosed raised cholesterol diagnosed more than
a year ago, no relevant family history, not referred to specialist
clinic, takes one statin tablet a day, last reading nine months
ago and GP confirmed it was well controlled, no other
risk factors.
Underwriting decision: OR for all benefits, no medical
evidence required (if all the required details can be obtained
from the application/client phone call).
What information do we need?
l
Date of diagnosis.
l
Last cholesterol reading and when it was taken.
l
Treatment, including referrals to a specialist clinic.
lOther
cardiovascular risk factors (height/weight, family
history, raised blood pressure, smoking).
If we don’t get enough information from the application, we
may request a nurse tele-interview. Or, if the condition appears
more severe, we may need a GP report.
Decision guide
Severity
CI
Life
IP
TPD
Well
controlled,
no other
risk factors
OR
OR
OR
OR
Suboptimal
control,
some other
risk factors
Mild/
Moderate
Mild/
Moderate
Moderate
Mild/
Moderate
Hospital
treatment,
poor
response to
treatment
Severe/
Decline
Decline
Decline
Decline
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Crohn’s disease
An inflammatory bowel disease which causes inflammation
of the digestive system (gastrointestinal tract). It is a chronic
(long-term) condition, although there can be long periods of
remission. The inflammation affects the body’s ability to digest
food, absorb nutrients and eliminate waste. Crohn’s disease can
sometimes cause problems outside the gastrointestinal tract.
Some sufferers, for example, will develop conditions affecting
the joints, eyes or skin.
What information do we need?
l
Date of diagnosis.
lDate
of last major attack (a major attack would
generally require specific treatment, eg steroids or
immunosuppressants and/or hospital admission).
l
Frequency and severity of symptoms.
l
Date and details of any surgery.
lTreatment.
If we don’t get enough information from the application, we
may request a nurse tele-interview. Or, if the condition appears
more severe, we may need a GP report.
Please note:
lCrohn’s
disease is a named condition under our critical
illness cover, so we’re likely to apply an exclusion.
lIf
it’s less than a year since diagnosis or the last major
attack, we won’t be able to offer critical illness cover.
Decision guide
Severity
Life
CI
IP
TPD
In remission
or
intermittent
minor
symptoms
Mild
Exclusion
Decline
Exclusion
More
frequent
symptoms,
steroids
or similar,
hospital
admissions
Mild/
Moderate
Exclusion
Decline
Decline
Frequent/
continuous
symptoms,
hospital
admissions,
poor
response to
treatment.
Severe/
Decline
Decline
Decline
Decline
Case study:
Client (age 46) disclosed Crohn’s disease diagnosed three years
ago. A nurse tele-interview confirmed the last major attack
was two years ago, occasional minor symptoms, no hospital
admissions and no continuous treatment.
Underwriting decision: +25 for life, CI accepted OR with
Crohn’s exclusion, exclusion for TPD, IP declined.
Further Reading: Crohn’s and Colitis UK,
http://www.crohnsandcolitis.org.uk/
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Depression/Anxiety
What is the condition?
Various conditions including depression, anxiety, stress, bipolar
disorder and schizophrenia.
What information do we need?
lDiagnosis.
l
Date of onset.
l
Frequency and severity of symptoms.
lTreatment,
including referrals to a psychologist or
psychiatrist.
l
Time off work.
lDetails
of any episodes of self harm, suicide attempts or
suicidal thoughts.
Severity
Life
More
significant
depression,
more
frequent
time off,
poor
response to
treatment,
possible
hospital
inpatient
Moderate/
Decline
CI
IP
Moderate/ Decline
Decline
TPD
Decline
Case study:
If we don’t get enough information from the application, we
may request a nurse tele-interview. Or, if the condition appears
more severe, we may need a GP report.
Client disclosed a single episode of depression related to
bereavement, onset 18 months ago, no longer having any
treatment, no history of self harm or suicidal thought.
Decision guide
Underwriting decision: OR for life and CI, TPD and IP
accepted with a nervous disorders exclusion.
Severity
Mild
anxiety,
stress or
depression
CI
Life
OR
Mild/
More
Moderate
frequent
symptoms
of anxiety/
depression,
possible
hospital
treatment as
outpatient,
some time
off work
IP
TPD
OR
Exclusion
Exclusion
OR/ Mild
Exclusion
Exclusion
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Diabetes
What is the condition?
Case study:
A chronic condition associated with abnormally high blood
sugar levels due to the body’s inability to produce sufficient
insulin (or to respond to the insulin it produces). Type 1
diabetes – the body produces no insulin whatsoever, and insulin
injections are required. Type 2 diabetes – the body produces
insulin, but in insufficient quantities, or the body produces
insulin but becomes resistant to it. Diabetics can suffer major
complications, such as heart disease, stroke, kidney failure
and blindness.
Client (age 45) disclosed Type 1 diabetes diagnosed 20 years
ago – a copy of his medical records was obtained which
revealed:
Type 1 diabetes diagnosed 20 years ago, no complications
or other risk factors (eg blood pressure, FH, kidney problems,
overweight), excellent diabetic control, no hospital admissions.
Underwriting Decision: +125 for life. CI, IP and TPD declined.
Further Reading: Diabetes UK, www.diabetes.org.uk
What information do we need?
Depending on the details given on the application, we may
be able to make an immediate decision. Alternatively, a GP
report will be required. The decision will depend on the type,
when diagnosed, how well the condition is controlled, and
the presence of any complications or other cardiovascular
risk factors (height/weight, family history, raised cholesterol,
smoking)
We are unable to offer critical illness cover or income protection
for diabetics.
Decision guide
Severity
Depends
on multiple
factors,
including
type, age,
control,
date of
diagnosis,
other risk
factors
Life
Mild to
Decline
CI
Decline
IP
Decline
TPD
Decline
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Heart attack
What is the condition?
Case study:
Death of a portion of the heart muscle due to a sudden
interruption in the blood supply.
Client (age 55) disclosed a heart attack – a copy of his medical
records revealed:
Heart attack three years ago, classed as moderate (angiography
showed disease in two major vessels), on treatment for
hypertension, latest blood pressure reading slightly raised, no
other risk factors.
What information do we need?
A GP report.
Please note:
lOur
decision will depend on the applicant’s age, frequency
and severity of symptoms, the extent of the heart disease
(how many vessels are affected, if known), and the presence
of any other risk factors.
Underwriting decision: +250 (including +50 for blood
pressure) for life. CI, IP and TPD declined.
Further Reading: British Heart Foundation, www.bhf.org.uk
lWe
can’t offer any cover if the applicant was under 40
when the condition started.
lIf
the heart attack was within the last six months, we’ll
postpone cover.
lWe
can’t offer any cover if the applicant has had a heart
attack and has diabetes.
lWe
can’t offer critical illness cover or income protection for
an applicant who has had a heart attack.
Decision guide
Severity
Depends
on age,
symptoms,
results of
investigations,
other risk
factors
Life
Mild to
Decline
CI
Decline
IP
Decline
TPD
Decline
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Irritable bowel syndrome (IBS)
What is the condition?
Case study:
A long-term condition of the digestive system, causing bouts of
abdominal cramps, bloating, diarrhoea and/or constipation. The
exact cause is unknown, but it is thought to be related to overactivity or increased sensitivity of the gut. Psychological factors
such as anxiety or stress also play a part.
Client disclosed IBS diagnosed two years ago, not awaiting
hospital referral/investigations/surgery, no suspicion of ulcerative
colitis or Crohn’s disease, no anxiety/stress/depression symptoms
requiring treatment, three days off in the last two years.
What information do we need?
l
Date of diagnosis.
l
Frequency and severity of symptoms.
l
Investigations carried out.
l
Time off work/impact on daily activities.
l
Mental health symptoms.
Underwriting decision: OR for all benefits, no medical
evidence required (if all the required details can be obtained
from the application/client phone call).
Please note:
Our decision will depend on the applicant’s age, frequency
and severity of symptoms, the extent of the heart disease (how
many vessels are affected, if known), and the presence of any
other risk factors.
Decision guide
Severity
CI
Life
IP
TPD
Mild, nonincapacitating
symptoms
OR
OR
OR
OR
More
frequent
and/or severe
symptoms,
time off work
OR/Mild
OR/Mild
Mild/
Exclusion
Mild/
Exclusion
Frequent/
continuous
symptoms,
psychological
symptoms
Mild/
Mild/
Moderate Moderate
Moderate/ Moderate/
Exclusion/ exclusion/
Decline
Decline
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Multiple sclerosis (MS)
What is the condition?
Case study:
An inflammatory disease of the central nervous system. Signs
and symptoms include muscle weakness, tremor, disturbance of
speech and vision, and bladder dysfunction.
Client (age 32) disclosed MS – a copy of her medical
records revealed:
The most common type of MS is described as relapsing
remitting MS. It’s characterised by recurrent attacks of
symptoms with periods of remission in between. With
progressive MS, symptoms continue to get worse over time,
with no distinct periods of remission.
MS diagnosed two years ago, relapsing remitting type,
moderate disability but quite self-sufficient and socially active,
unable to work full-time but can walk unaided.
Underwriting decision: +150 for life. CI, IP and TPD declined.
Further Reading: Multiple Sclerosis Society UK,
www.mssociety.org.uk
What information do we need?
A GP report.
Please note:
lOur
decision will depend on the type, frequency and severity
of symptoms and the degree of disability.
lWe
can’t offer critical illness cover or income protection for
an applicant with MS.
Decision guide
Severity
Life
CI
IP
TPD
No or minimal Mild/
Moderate
signs and
symptoms
Decline
Decline
Decline
Moderate
disability but
self-sufficient
Moderate/
Severe
Decline
Decline
Decline
Requires
assistance
with mobility
and/or
diagnosed as
progressive
Severe/
Decline
Decline
Decline
Decline
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Stroke (CVA)
What is the condition?
Permanent damage to an area of the brain caused by a sudden
interruption in the blood supply. This can be due to a blockage
in one of the blood vessels supplying the brain or a bleed in the
brain. Most strokes occur when a blood clot blocks an artery.
What information do we need?
A GP report.
Please note:
lOur
decision will depend on the applicant’s age, type and
severity of stroke, the severity of any residual symptoms, and
the presence of any other cardiovascular risk factors (height/
weight, family history, raised blood pressure/cholesterol,
smoking).
lWe
can’t offer any cover if the applicant is under 46 at the
time of application.
the stroke was within the last six months, we’ll
postpone cover.
Decision guide
Severity
Life
CI
IP
TPD
Single episode,
full recovery
within 6
months
Moderate/
Severe
Decline
Decline
Decline
Single episode,
some residual
symptoms
Severe
Decline
Decline
Decline
More than
one episode or
severe residual
symptoms
affecting daily
activities,
unable to
function
independently
Decline
Decline
Decline
Decline
lIf
lWe
can’t offer any cover if the applicant has had a stroke
and has diabetes.
lWe
can’t offer critical illness cover or income protection for
an applicant who has had a stroke.
Case study:
Client (aged 56) disclosed a stroke 18 months ago – a copy of
his medical records revealed:
Stroke due to cerebral embolism, some residual symptoms but
able to walk using a stick, slight memory impairment, no other
risk factors, returned to part-time work in a less manual job.
Underwriting decision: +150 for life. CI, IP and TPD declined.
Further Reading: Stroke Association, www.stroke.org.uk
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Ulcerative colitis
What is the condition?
Severity
An inflammatory bowel disease which causes inflammation and
ulceration of the lining of the rectum and colon (large intestine).
It is a chronic (long-term) condition, although there can be long
periods of remission. Ulcerative colitis can cause complications
outside the digestive system – some sufferers will develop
problems with the joints, eyes and skin. It can also be a risk
factor for colon cancer.
What information do we need?
Frequent
major
attacks
requiring
hospital
admissions
and frequent
or
continuous
oral steroids
Life
CI
Moderate/ Decline
Severe
IP
Decline
TPD
Decline
l
Date of diagnosis.
l
Extent of disease, if known.
Case study:
l
Frequency and severity of symptoms.
l
Date and details of any surgery or hospital admissions.
Client (age 44) disclosed ulcerative colitis – a copy of her
medical records revealed:
lTreatment.
lAssociated
problems, eg joint/skin/eye problems related to
UC (if so, critical illness cover is likely to be declined).
If we don’t get enough information from the application, we
may request a nurse tele-interview. Or, if the condition appears
more severe, we may need a GP report.
Ulcerative colitis diagnosed five years ago, no surgery, symptoms
mild but frequent/continuous, distal disease (limited to the
left side of the colon), not underweight, no complications, no
hospital admissions.
Underwriting decision: OR for life. CI and TPD +50, IP +100.
Further Reading: Crohn’s and Colitis UK,
www.crohnsandcolitis.org.uk
Decision guide
Severity
Life
CI
IP
TPD
Occasional
attacks,
good
response to
treatment,
limited
disease
OR/Mild
Mild/
Moderate
More
frequent
attacks,
use of oral
steroids or
similar, more
extensive
disease
Mild/
Moderate
Moderate/ Moderate/ Moderate/
Severe
Exclusion
Exclusion
Mild/
Mild/
Moderate/ Exclusion
Exclusion
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Underwriting Factors
Here we explain in more detail the common factors that
underwriters use in their assessment:
l
Medical history
lBuild
lSmoking
lAlcohol
lDrugs
lResidence
lFinancial
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Medical History
Why the biology lesson?
The biggest factor in underwriting relates to an individuals
medical history. To understand how diseases can affect an
individual it is therefore important to have an understanding of
how the body works.
There follows therefore short chapters on the following:
l
The Digestive System
l
The Respiratory System
l
The Endocrine System
l
The Central Nervous System
l
Mental Illness
l
The Musculoskeletal System
l
Tumours
l
Build
Each chapter includes a short test. Answers are in the appendix 2.
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The Digestive System
The digestive tract runs from the mouth, through to the anus
and can also be referred to as the alimentary canal.
The alimentary canal is divided into three sections:
The first section consists of the mouth, pharynx, oesophagus
(esophagus) and stomach.
The second section consists of the small intestines; duodenum,
jejunum and ileum.
The third section consists of the large intestines; caecum, colon
and rectum.
Partoid
Gland
Sublingual
Gland
Submandibular
Gland
Esophagus
Liver
Stomach
Glossary
Term
Definition
Hemi
Half. Hemigastrectomy means the removal
of half of the stomach
Gastritis
Inflammation of the stomach
Gastrectomy
Excision/removal of the stomach
Hemigastrectomy
Excision/removal of half of the stomach
Gastrostomy
The making of an artificial opening into the
stomach
Hepatitis
Inflammation of the liver
Hepatocele
Hernia of the liver
Cheil, chil
Lip. Cheilitis means inflammation of the lip
Gloss
Tongue. Hemiglossectomy means the
removal of half of the tongue
Cholecyst
Gall bladder. Cholecystitis means
inflammation of the gall bladder.
Cholecystectomy means the removal of the
gall bladder
Enter
Intestine. Enteritis means inflammation of
the intestine
Gingiva
Gums. Gingivitis means inflammation of the
gums
Ile, eile
Ileum. This is the final section of the small
intestine
Proct
Rectum, anus. A proctologist specialises in
the study of disorders of the rectum or anus
Pylor
Pylorus. This is the opening between the
stomach and the duodenum
Spasm
Involuntary contraction (enterospasm)
Viscer
Organ. This is used to refer to the internal
organs, for example, the stomach, gall
bladder, spleen etc
Gallbladder
Spleen
Duodenum
Splenic Flexura
of Transverse
Colon
Pancreas
Hepatic
Flexure
Acending
Colon
Transverse
Colon
The parts that make up the alimentary canal are as follows:
Jejunum
Pharynx
Ileum
Decending
Colon
Cecum
Sigmoid
Colon
Appendix
Rectum
Sigmoid
Flexure
The pharynx is a muscular pouch lined with a mucous
membrane. It is located at the back of the mouth and acts as an
airway during respiration and as a passageway for food.
Oesophagus
The oesophagus propels food down towards the stomach, using
its muscles to produce a wave-like motion. The term used for
this wave-like motion is peristalsis.
Anus
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Cardiac sphincter
Anal sphincter
This is found at the base of the oesophagus. It is a ring-like
muscle, which relaxes to let food into the stomach. It is called
cardiac as it is at the same end of the stomach as the heart.
The opening and closing of the anus is controlled by the internal
and external sphincters, which control the passage of waste
from the rectum.
Stomach
The liver
Food passes through the cardiac sphincter into the stomach,
where digestion takes place.
The liver is the biggest gland in the body. It is called a gland
because it secretes bile.
Pyloric sphincter
It is essential in the metabolism of proteins, fats and
carbohydrates.
Food passes out of the stomach through the pyloric sphincter
into the duodenum. The pyloric sphincter is at the other end of
the stomach to the cardiac sphincter.
Although the liver secretes the bile, once it has been secreted,
the bile is stored in the gall bladder.
Duodenum
Right Hepatic
Duct
The bile that is produced by the liver and stored in the gall
bladder empties into the duodenum to break down fats.
Pancreatic juices also enter the duodenum via the pancreatic
duct to aid digestion.
Jejunum
Liver
Gallbladder
From the duodenum, food passes into the jejunum, where
further enzymes are secreted for digestion.
Ileum
Food then passes from the jejunum to the ileum. The majority
of food absorption takes place here.
Caecum
The caecum is a pouch, which connects the ileum and the
ascending colon of the large intestine.
Cystic
Duct
Duodenum
Left Hepatic
Duct
Stomach
Common
Hepatic
Duct
Pancreatic
Duct
Pancreas
Common
Bile Duct
Large intestine
Hepatitis
The remaining food is passed to here.
Hepatitis is a very serious disease that causes the liver cells to
die. The liver tries to compensate for the dying cells by getting
bigger. The enlargement of the liver is called hepatomegaly. The
spleen may also become enlarged.
Colon
The colon consists of the ascending colon, the transverse colon,
the descending colon and the sigmoid colon. Together, they
make the last portion of the digestive system. The colon extracts
water and salt from food before they are eliminated from the
body by the rectum.
Rectum
The upper part of the rectum is lined with a mucous membrane.
The last inch of the rectum is the anal canal. Once excess water
has been absorbed by the colon, solid waste passes to the
rectum. It leaves the body through the anus.
If the hepatitis is chronic, or long lasting, a progressive
destruction of the liver cells occurs, along with changes in the
fibrous connective tissue.
The disease can result in terminal cirrhosis of the liver. This is
where the liver becomes hard due to changes in the fibrous
portion. Cirrhosis can also be caused by nutritional deficiencies
and alcoholism. Cirrhosis often leads to liver failure.
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Cholecystitis
There are three main forms of hepatitis:
Form
Description
Hepatitis A
This is the most common form and can occur
either in epidemics or sporadically
Hepatitis B
This form of the disease is spread by bloodto-blood contact. The most common methods
of transmission are blood transfusions, sexual
contact and the use of infected needles. The
sufferer may also be at risk of contracting HIV
Hepatitis C
This can be spread by the same methods as for
hepatitis B
The treatment for hepatitis is rest, medication and abstinence
from alcohol.
Hepatitis can be diagnosed by carrying out liver function tests
(LFTs), which are blood tests that measure the presence of
various chemicals and enzymes in the blood. A Liver biopsy
can also aid in diagnosis. This is where a small piece of the liver
is removed by inserting a biopsy needle through the skin. The
tissue that is removed by the biopsy needle is then examined.
Cirrhosis of the liver
Cirrhosis of the liver can be caused by alcoholism. The normal
tissue of the liver is replaced by fibrous scar tissue, leading to
loss of liver function.
The gall bladder
The gall bladder is a membranous sac, which serves as a store
for bile secreted by the liver.
Bile is important for digesting fats. It is also the route by which
many substances are excreted from the body.
Common
Hepatic
Duct
Gallbladder
Common
Bile Duct
If the stones are small and few, there is usually no problem.
However if they are large or numerous, they can cause
problems if not removed. The procedure for the removal of the
gall bladder is cholecystectomy.
Crohn’s disease
Crohn’s disease is an inflammation of the ileum, which is the
lower part of the small intestine. It may extend to involve other
parts of the digestive tract; sometimes all of it, from the lips to
the anus.
Patches of normal intestine can be interlinked with diseased
intestine. It can affect the full thickness of the intestinal wall
and spread to adjacent organs, for example, the bladder.
Affected segments of the bowel become fibrosed and fistulae
may develop. Fistulae are unnatural narrow channels leading
from the interior of the bowels to the surface.
All forms of hepatitis are life threatening.
Cystic Duct
Cholecystitis is inflammation of the gall bladder. It is often
associated with the presence of stones, usually formed by
hardened cholesterol. Gall stones are known as cholelithiasis.
The word Lith means stone.
The disease is usually chronic (of long duration) and relapsing,
although complete remission may occur.
The symptoms of crohn’s disease are diarrhoea and abdominal pain.
Although there is no cure, it is advised that sufferers eat a low
fibre diet to treat the diarrhoea and take iron supplements
and vitamins for the malabsorption the disease causes. Drugs
(immunosuppressants) can be prescribed, and only if all other
treatments fail to have an effect may steroids be recommended.
However, whilst steroids may relieve the symptoms, they will
not cure them and may result in further complications and
undesirable side effects, such as peptic ulcers. The higher the
prescribed dose, the more chance there is of side effects and
complications.
There are two surgical procedures that can be carried out in
chronic cases of crohn’s disease. The first is a proctocolectomy/
ileostomy. This is an excision of part of the colon and all
of the rectum, creating an opening in the abdominal wall,
through which the ileum is threaded. The other procedure is a
colectomy/Ileorectal anastomosis, whereby the colon is removed
and the free end of the ileum is joined to the rectum. This
procedure has a likely recurrence rate of 50%.
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Crohn’s disease can be diagnosed by a barium enema. Radioopaque barium sulphate is inserted into the colon. It is moved
about by the patient changing position. X-rays are taken at
intervals, revealing any inflammation. The other method of
diagnosis is a sigmoidoscopy, whereby the sigmoid colon,
rectum and anus are viewed using a long flexible fibre optic
instrument called a sigmoidoscope, which is passed through the
large intestine.
Normal
The following terms are used to describe the extent of colonic
involvement:
Term
Description
Distal
Only the rectum to the sigmoid colon is
affected
Substantial
The area to the descending colon, but not
further than the mid-transverse colon is
affected
Total
The entire colon is affected
Treatments can include a change in diet, codeine phosphate,
anti-inflammatory drugs, steroid enemas and oral steroids.
However, although oral steroids may lead to remission, they do
not reduce the frequency of further attacks.
The same diagnosis and surgical procedures may be carried out
for the treatment of ulcerative colitis as for crohn’s disease.
Normal
Inflamed
Ulcerative colitis
Ulcerative colitis (UC) is a non-specific inflammatory disease of
the colon and rectum.
It is characterised by recurring diarrhoea, in which mucus and
blood from ulcerations of the bowel, are mixed with faeces.
There is a risk of malignancy of the colon and rectum in long
standing severe sufferers.
It is limited to the large bowel (caecum to rectum) and only the
lining of the bowel is affected.
The extent of the disease correlates with age, the mode of
onset and the severity of symptoms.
Disease affecting only the descending colon, typically presents
itself in middle life. The symptoms are usually fairly mild and
easily controllable. At the other extreme, disease affecting
virtually the entire colon is abrupt at onset and presents itself at
an early age. The symptoms are severe and difficult to control.
Colon with
ulcerative colitis
Irritable bowel syndrome (IBS)
IBS is a functional disorder of bowel rhythm, producing
diarrhoea, constipation or abdominal pain. There is no
inflammation or ulceration of the bowel and no traces of blood
in the stools. It is most commonly encountered by people who
are easily stressed or worried. It is not a life threatening illness.
The treatment of IBS is a high fibre diet and anti-spasmodic
drugs to relive abdominal pain.
A barium enema will reveal any ulceration, which aids in
diagnosis. However, investigations for IBS are carried out more
to rule out anything more sinister, rather than to detect IBS.
Hernias
A hernia is the protrusion of an organ through a muscular body
wall/natural orifice, into another organ.
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A hiatus (hiatal) hernia is the protrusion of part of the stomach
through the opening where the oesophagus goes through the
diaphragm.
This may result in chest pain, which is almost indistinguishable
from cardiac pain.
An inguinal hernia is a protrusion from the inguinal canal into
the groin.
Oesophagus
Hiatus
Portion of stomach
herniated through hiatus
Diaphragm
peptic ulcers may lead to bleeding or
perforation, emergency situations
Lower oesophageal
sphincter
If surgery is required, the following procedures may be conducted:
Stomach
Peptic ulceration
The stomach is a muscular, curved, pouch-like structure located
towards the left side of the abdominal cavity. It is lined with
a thick mucous membrane, which protects the muscular wall
from the strong acids secreted by the stomach. Sometimes, the
strong secretions eat away at the stomach wall. The mucous
lining is corroded, causing an ulcer.
Peptic ulceration commonly affects the stomach (gastric) and
the duodenum, but it may also affect the oesophagus. It is
sometimes due to over-secretion of acidic digestive juices,
or the inability of the alimentary canals to withstand them.
Haemorrhage and perforation can sometimes occur as a result
of peptic ulceration.
The symptom of peptic ulceration is recurrent dyspepsia
(heartburn/indigestion).
Procedure
Description
Partial
gastrectomy
This is carried out for gastric and duodenal
ulcers
Vagotomy
For duodenal ulcers, the vagus nerve, which is
responsible for stimulating the production of
acid, is severed
Pyloroplasty
The widening of the pyloric channel at the
lower end of the stomach.
Total
gastrectomy
This is rarely used for benign ulcers, unless they
are very large
One of the methods of investigation in the diagnosis of peptic
ulceration is a gastroscopy. The patient is required to fast for
four hours. A fibre-optic instrument is then passed via the
oesophagus into the stomach. Material may be taken for
examination and/or photographs of the stomach are taken.
Ulcers can respond to stress, which stimulates gastric secretions
or over-active gastric glands, causing trauma to the internal
stomach lining.
Another method is a barium meal, which is a liquid containing
barium sulphate. When swallowed, it shows up on x-ray,
and can be used to obtain pictures of the stomach and small
intestine.
The other causes could be an obsessional personality, which
creates stress in itself, diet and/or alcohol, cigarette smoking
and drugs, for example, aspirin.
Alternatively, a biopsy could be carried out to establish the
precise diagnosis.
The methods used to treat peptic ulceration are diet restrictions,
relaxation, abstinence from alcohol and cigarettes, antacids to
neutralise the acidity and H2 blockers to reduce acid secretion.
H2 blockers are often prescribed long term.
Surgery for peptic ulcers is rare, and usually only if the
condition is persistent and doesn’t respond to any of the other
treatments, or if there is a risk of the ulcer perforating.
Haemorrhoids
Haemorrhoids (piles) are inflamed varicose veins, located at the
opening of the anal canal. They can become quite swollen and
painful, sometimes requiring surgery to remove them.
Haemorrhoids are not life-threatening.
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The Respiratory System
Respiration is the name given to the process by which the body
obtains oxygen and eliminates carbon dioxide waste. The body
exchanges these gases in the lungs and cells.
Oxygenated air enters the body through the nose or mouth. It
then passes through the larynx/voicebox before passing through
the trachea. The trachea divides into the right and left bronchi.
The air then passes through the bronchi to the lungs.
Trachea
Nasal Cavity
Pharynx
Oral Cavity
Epiglottis
Tongue
Larynx
Trachea
Pleura
Bronchus
Right Lung
Left Lung
The trachea is a tube made of cartilage, lined with a
mucous membrane. It lies in front of the oesophagus and is
strengthened by a row of c-shaped rings. The open end of the c
is pointed towards the oesophagus.
Bronchi
The right bronchus is shorter and wider than the left bronchus.
The bronchi have c-shaped rings, like the trachea. They are lined
with a layer of ciliated (hairy) mucous membrane that sweeps
out dust and dirt particles.
Lungs
Diaphragm
Glossary
Term
Definition
Centesis
Puncture. Thoracentesis is a puncture of
the thorax
Hemi
Half
Pnoea
Breath. Dyspnoea means difficult or
painful breathing
Bronch
Bronchus (one of the two bronchi)
Laryng
Larynx (voice box)
Pharyng
Pharynx (the tube that connects the
mouth and nasal passages with the
esophagus)
Pulmo
Lung
Pneum/pneumon
Lung/air
Thorac
Thorax/chest. Thoracotomy means an
incision into the thorax
When the bronchi enter the lungs, they divide into smaller
structures called secondary bronchi. These then divide into
bronchioles.
The bronchioles finally terminate in alveolar ducts, each with an
attached alveolar sac. Combined, these are referred to as the
bronchial tree.
As the secondary bronchi and bronchioles divide, the walls
become thinner and more elastic. When they get to the alveolar
sacs, which are made up of bunches of alveoli, the rings of
cartilage disappear.
The alveoli are one cell thick and are permeable to gas. Behind
these are capillaries from the lungs. It is here that the exchange
of oxygen and carbon dioxide takes place.
Pleura
Trachea
Right Main
Bronchus
Ribs
Respiration supplies the cells with an adequate amount of fresh
oxygen. It also eliminates the carbon dioxide waste that would
otherwise poison the body cells, removes water from the body
and helps to maintain the normal temperature of the body.
For respiration to occur, we need plenty of oxygen in the air, a
moist and permeable membrane for the oxygen to pass through
and a moving blood supply containing a high carbon dioxide
content. This is so that the body can exchange one gas for the
other.
Bronchioles
Alveoli
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Each lung is located in a separate cavity (space) called a pleural
cavity. The pleural cavities are housed in a much larger cavity;
the thoracic cavity. This is the thorax (chest).
At the base of the thoracic cavity is the diaphragm, which is a
large dome shaped muscle. This is the main muscle of respiration.
When you inhale, the diaphragm contracts, flattens and moves
down so that the thorax and lungs have room for the incoming
air. When you exhale, it relaxes and returns to its original position.
Asthma can be diagnosed by performing a clinical examination,
whereby a doctor will check for abnormal chest sounds; for
example, rhonchi (wheezing) and rales (rattling). Lung function
tests can also aid diagnosis. This method requires the patient
to breathe into a spirometer. The passage of air through the
lungs is measured when the patient exhales. The age, height
and weight of the patient are recorded and used to predict the
normal ranges.
The different lung function tests include:
Bronchial asthma
Bronchial asthma is characterised by wheezing and dyspnoea.
It is usually triggered by spasms of the bronchial tubes. It may
be caused by external factors, for example, pollen, dust or
certain food allergies. It can also be caused by infection, sudden
changes in body temperature or even emotional upsets.
Normal Airway
Lining
Airway in Person
With Asthma
Tight Muscles
Swelling
Muscle
Mucus
Extrinsic asthma (allergic)
This form of asthma tends to appear in childhood. Attacks are
usually mild, and often relate to external factors, such as dust or
pollen. Attacks tend to diminish as the individual grows older,
sometimes dying out altogether in adolescence.
l
Peak expiratory flow rate (PEFR/PEF/PFR)
l
Forced expiratory volume (FEV)
l
Forced vital capacity (FVC)
Allergy tests can also be conducted to help in the diagnosis
of asthma. The patient is exposed to a specific antigen, for
example, food, dust, animals etc. If the patient’s system
is intolerant to a particular antigen, this will result in pain,
feverishness or a rash.
Chest X-rays produce photographic records of the structure and
condition of the chest, which are also important in diagnosis.
Acute bronchitis
Acute bronchitis is inflammation of the mucosal lining of the
bronchi, secondary bronchi and the bronchioles. It is usually due
to infection caused by either the coryza virus or influenza virus.
If the lungs and bronchi are otherwise healthy, the attack is
usually brief and resolves leaving no residual damage.
Intrinsic asthma (late-onset)
This form of asthma first occurs in adult life. Attacks are usually
severe and the risk of death is higher than in the extrinsic form.
The treatments for asthma are as follows:
Treatment
Description
Antibiotics
These drugs are used when an acute
infection is present
Broncho-dilators
These help to relax the bronchial tubes,
allowing the air to pass more freely
through the lungs
Inhalers
These are also broncho-dilators. In
addition to the tablet form, the drug can
also be inhaled
Steroids
Used to relieve symptoms of dyspnoea
and wheezing
Phlegm in Alveoli
Bronchitis
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Chronic bronchitis
Chronic bronchitis is the hypersecretion of mucus by the glands
in the lining of the bronchi.
In the early stages of the disease, this is the only abnormality.
In the later stages, there is structural damage to the bronchi.
This causes irreversible narrowing of the airways.
Two conditions are necessary for the development of
the irreversible stage of chronic bronchitis. These are; a
constitutional, or inherited, predisposition to disease of the
respiratory tract, or the continuous presence of an irritant to the
bronchial mucosa. The worst irritant is inhaled tobacco smoke,
particularly of cigarettes.
The treatments for bronchitis are either antibiotics, which kill
the infection, or broncho-dilators, which are used if the patient
is wheezy or is suffering from bronchospasm (an involuntary,
painful contraction of the bronchus).
The following investigations can be conducted to aid in the
diagnosis of bronchitis:
Investigation
Description
Clinical
examination
A doctor will check for abnormal chest
sounds
Sputum culture
Material, mainly consisting of saliva
and mucus, is spat from the mouth and
analysed
Chest x-rays
Photographic records of the structure and
condition of the chest are examined
Lung function
tests
is encouraged to cough up as much secretion from the lungs
as possible. Sometimes, therapeutic drainage is used. The
patient’s head is placed so that the trachea will be inclined
below the affected lung. Surgery may be carried out, depending
on the degree of damage to the lung. The following surgical
procedures may be performed:
Procedure
Description
Segmental
resection
An excision of one or more segments of
a lobe
Lobectomy
An excision of one or more lobes of
either, or both lungs
Pneumonectomy
The removal of an entire lung
Bronchiectasis is diagnosed using the same investigations as is
used to diagnose bronchitis.
Emphysema
Emphysema is a chronic, incurable disease, which is caused
by the distension of the alveoli. It is often associated with
advanced chronic bronchitis. The alveoli are only one cell
thick and are permeable to gas. It is here that the exchange
of oxygen and carbon dioxide takes place. The onset of
emphysema is often due to cigarette smoking. The symptoms
consist of coughing, an increase in shortness of breath on
exertion, a barrel chest (where the chest is hyperinflated and
rigid) or hyperinflated lungs.
Bronchi
The patient breathes into a spirometer
and the passage of air through the lungs
is measured. Age, height and weight
are recorded and used to predict normal
ranges.
Bronchiectasis
Bronchiectasis may be congenital or acquired. It is characterised
by the dilation (widening) of the smaller bronchial tubes and
the bronchi. It can affect one lung (unilateral) or both (bilateral).
Symptoms consist of a chronic persistent cough and respiratory
infections. Sufferers are also vulnerable to other lung disorders.
Recurrent infections, together with continued cigarette smoking
may lead to chronic bronchitis.
Overinflated
Alveolus
Antibiotics can be used to clear infections in the treatment of
less severe bronchiectasis. Another method of treatment used
is postural drainage, whereby the patient lies head down and
Normal Alveoli
Emphysematous
Alveoli
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Musicians that play wind instruments are vulnerable to this
disorder.
There are no real treatments for this irreversible disease,
however antibiotics are prescribed when an infection is present.
To diagnose the condition, a doctor may check for abnormal
chest sounds, use chest x-rays, which will show hyperinflated
lungs, or carry out lung function tests.
Pneumoconiosis
Pneumonia
Pneumonia is also known as pneumonitis. It is an acute,
infectious disease, characterised by the inflammation of
the lung. Pneumonia can occur in association with other
serious disorders, for example AIDS, alcoholism, diabetes or
cardiovascular disease.
Chest x-rays and a sputum culture are the main methods used
in diagnosis. Once diagnosed, a course of antibiotics will be
prescribed to kill the infection.
Pneumoconiosis is caused by a reaction of lung tissue to the
presence of organic dust, of neither animal nor vegetable origin.
Almost invariably, it is due to prolonged occupational exposure.
The two main types of pneumoconiosis are non-collagenous
(simple) and collagenous.
Collagen is a protein constituent of fibrous tissue.
The following conditions are usually symptom-less, but a chest
x-ray will reveal their presence:
Condition
Cause
Non-collagenous
pneumoconiosis
The inhalation of inert materials
Siderosis
The inhalation of iron
Coalworkers
pneumoconiosis
The inhalation of carbon
The symptoms of the following conditions are dyspnoea and a
dry irritating cough:
Condition
Cause
Collagenous
pneumoconiosis
The inhalation of fibrogenic dust (dust
originating from fibres)
Asbestosis
The inhalation of asbestos dust. This is
also associated with carcinoma (cancer) of
the lungs
Silicosis
The inhalation of silica dust. This
condition is mainly found in workers
quarrying granite and sandstone, or
mining copper, silver or gold
These conditions are diagnosed by clinical examination, chest
x-rays, lung function tests or a lung biopsy, whereby tissue from
the lung is removed and examined.
There is no specific treatment for these conditions, but a change
in occupation is recommended to avoid continued exposure.
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The Endocrine System
Endocrine means to secrete within.
The endocrine system consists of glands that control and
regulate many of the body’s activities, by slowly secreting
complex chemical substances into the blood stream.
Pineal
Hypothalamus
Pituitary
Thyroid
Parathyroids
The substances are called hormones. Each hormone causes a
response in a specific organ or group of cells.
Hormones regulate the metabolic functions of the body,
regulate chemical reaction rates and influence the ability of
substances to transport themselves through cell membranes.
The glands that secrete these hormones are ductless, as they
have no ducts to carry away hormones; they are secreted
directly into the blood.
There are two different types of hormones:
Thymus
Adrenals
Pancreas
Ovary
Hormone type
Description
General
hormones
These hormones effect a distant organ or
tissue
Local hormones
These are released by a gland within a
tissue or organ
Testes
Low concentration of a particular hormone in the blood triggers
its release by its gland. Once the hormone level in the blood has
increased, the gland will stop secreting it.
Glossary
Term
Definition
Albumin
Protein. Albuminuria means protein in the urine
When a hormone has performed its function, it is destroyed;
either by the liver, or the tissues of the target organ. Once
destroyed, they are removed from the body by the kidneys.
Glyco/gluco
Sugar/sweet. Hyperglycaemia means there is
too much sugar in the blood
There are nine glands in the endocrine system.
Meli/melit
Honey/sweet. Also melli, as in diabetes mellitus
The thyroid gland
Supra
Above/beyond. Supra-occipital means
something above the occipital bone of the skull
The master gland of the endocrine system is the pituitary gland.
Crine
To secrete
Trophy
Growth/nourish. Hypertrophy means excessive
growth. Cardiac hypertrophy means an
increase in the size of the heart. Atrophy
means without growth
It is found at the base of the brain and is no bigger than the
size of a pea.
Megaly
Abnormal enlargement. Splenomegaly means
enlargement of the spleen, which can be
caused by leukaemia
Physis
Growth, as in growing (normal)
The hormones secreted by the pituitary gland control all other
glands in the system, including the thyroid gland.
One hormone secreted by the pituitary gland is the thyroid
stimulating hormone (TSH). This controls the activity of the
thyroid gland, which is in the neck.
Pituitary Gland
The complex activities of the body are stimulated by the Central
Nervous System (CNS) and the endocrine system.
The CNS uses nerve impulses to generate instant activity.
The endocrine system is more subtle in its approach. It works
by slowly releasing complex chemical substances into the blood.
They are released by the endocrine glands and control various
organs. The whole process is called secretion.
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The thyroid gland secretes three hormones:
Hormone
Effect
Thyroxine
This is essential for normal growth and
metabolism
Calcitonin
This hormone works with the parathyroid
glands to maintain the balance of calcium
in the body
Triiadothyronine
There is only a limited effect in the body
from this hormone
Thyroxine contains iodine. Its metabolic activity consists of burning
food at a slightly higher rate than normal.
Disorders of the thyroid gland
Most disorders of the thyroid gland are caused by overproduction
of thyroxine (Hyperthyroidism) or underproduction of thyroxine
(Hypothyroidism).
Larynx
Thyroid Gland
Isthmus
Trachea
l
Insomnia
l
Nervousness
l H
igh
metabolism (the person effected will lose lots of weight)
The treatments for hyperthyroidism can be either:
Drug
Effect
Anti-thyroid
drugs
These block the hormone production by the
gland
Radio-iodine
therapy
The patient is given a dose of radio-iodine
to drink, which stops the gland working
forever. The patient then has to be treated
for myxoedema.
Thyroidectomy
This means the removal of the thyroid
gland. However, this can cause
hypothyroidism.
Hypothyroidism
This is where there is under-activity of the thyroid gland. This
can cause cretinism. Cretinism is caused by the atrophy (wasting
away) of the thyroid in infancy. As a result, the skeleton stops
growing and there is a lack of mental development. Children
with thyroid atrophy are known as cretins. If no thyroxine
treatment is given, which results in dwarfism with stunted
sexual and mental maturity.
Hypothyroidism developed in a mature person is called
myxoedema. Myxoedema can occur due to damage to, or
removal of, the thyroid gland.
Thyroid deficiency can also be due the removal of part, or all,
of the gland for the treatment of benign enlargement or a
malignant tumour.
Symptoms of myxoedema include:
l
Face and hands become swollen/puffy
Hyperthyroidism (thyrotoxicosis)
l
Metabolism slows, causing fat to accumulate
This is where there is over activity of the thyroid gland and it
therefore causes an over secretion of thyroxine. This can cause
the gland to enlarge (goitre). A goitre may be due to a tumour
(usually benign but sometimes malignant) or a deficiency of
natural iodine.
l
Person becomes dull and apathetic
l
Higher mental activities grind to a halt
The treatment given for hypothyroidism is a thyroid hormone
drug, which replaces the missing hormone.
The symptoms of thyrotoxicosis are:
l
Protruding eyeballs
l
Quickened/irregular heart beat
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The following investigations can be undertaken to determine
whether a person is suffering from a thyroid disorder:
Investigation
Result
Clinical
examination
A doctor will look for signs, such as a puffy
face, protruding eyeballs etc
Blood tests, T3
and T4
These tests will determine the thyroxine
level in the blood
The islets of langerhans contain two types of cells important to
hormonal secretion:
Cell
Use
Alpha
Glucagons
Beta
Insulin
In the liver, glucagons helps to convert glycogen/glucose into
sugar. The body utilises this with the help of insulin.
Thyroid disorders can be life threatening if not treated and
controlled. Myxoedema can cause heart problems.
Diabetes mellitus
The pancreas
If too much insulin is produced, too much glucose is absorbed
into the cells of the body. This causes hypoglycaemia.
The pancreas is located behind the stomach. It has two types of
secreting cells; exocrine cells and endocrine cells.
Exocrine cells secrete pancreatic juices which contain enzymes
that act in the duodenum during the digestive process.
Esophagus
When the beta cells secrete too little insulin, a different problem
occurs; diabetes mellitus. The cells of the body are no longer
able to absorb sugar/glucose.
In normal people, food is converted to glucose, absorbed into
the blood and stored in the liver and muscles.
In diabetics, the sugar remains in the blood and the blood glucose
level rises. The body will dispose of the sugar into the urine.
Duodenum
The symptoms of diabetes mellitus can be:
Stomach
Left Lobe
of Pancreas
Right Lobe
of Pancreas
Traverse
Colon
Endocrine cells can be found in little clusters throughout the
pancreas. These clusters are called islets of langerhans. They
secrete glucagons and insulin.
l
Sugar in the urine
l
High blood pressure
l
Excessive thirst
It can also result in poor metabolism of carbohydrate, fat and
protein.
There are two forms of the disease; type 1, insulin dependent
diabetes mellitus (IDDM) or type 2, non-insulin dependent
diabetes mellitus (NIDDM). Some type 2 diabetics may end up
needing insulin injections if their condition is not controlled very
well.
Insulin increases cell permeability to glucose so that glucose
can get inside the cell. It also promotes storage of glycogen in
the liver and the utilisation of glucose by the tissue cells, so it
decreases the concentration of glucose in the blood
Type 1 diabetes
This usually affects people under the age of 35. The pancreas in
type 1 diabetes produces little or no insulin. The onset is abrupt.
The symptoms are polyuria (frequent need to pass urine), excessive
thirst, weight loss, weakness or lack of energy and finally, coma.
Insulin injections are necessary to control the condition and to
sustain life in type 1 diabetics.
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Type 2 diabetes
This mainly affects the middle aged and the elderly. The
condition develops when the pancreas produces some insulin,
but not enough. Symptoms occur gradually and sufferers are
usually overweight. Statistics show that one in three sufferers
has a family history of diabetes. It can be treated by diet alone,
but sometimes sufferers need oral drugs.
If diabetes is not controlled properly, you may see any of the
following conditions:
Condition
Description
Retinopathy
This is when there are red dots at the back
of the eye, which may cause blindness
Neuropathy
The legs and feet have a lack of sensation.
Sufferers may get ulcers or gangrene if the
conditions are severe
Nephropathy
This is a disease of the kidneys. Albuminuria
is a symptom of this disorder
Sugar in the urine is shown on a medical examination in
multiples of +. For example:
+= Very small amount
++
+++
++++= Very large amount
Most deaths in diabetics are due to heart and renal disease.
The three main treatments for diabetes mellitus are:
Treatment
Description
Insulin
injections
Genetically engineered human insulin
Oral
hypoglycaemics
These stimulate the islets to produce more
insulin or encourage tissue to take up and
store glucose. This in turn reduces blood
sugar levels
Diet
Suffers should monitor carbohydrate and
calorie intake
Anyone displaying symptoms of diabetes may be asked to take
a glucose tolerance test under strict hospital control. The patient
must fast from 22:00 the previous night and a blood sample is
taken during fasting. The patient then drinks a glucose solution
and a further blood test is taken two hours later.
Depending on the level of glucose remaining in the blood after
two hours, the patient may either have a negative result, be
diagnosed with impaired glucose tolerance, or be diagnosed
with diabetes.
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Central Nervous System
The nervous system consists of:
The brain
Central nervous system (CNS)
The brain lies within the cranial cavity and is the main decision
making and control centre of the body.
Including the brain and spinal cord
Peripheral nervous system (PNS)
Including the nerves connected to the spinal cord
Autonomic nervous system (ANS)
Including the nerves which activate those muscles not under
voluntary control. For example, cardiac and all smooth muscles
and glands
The brain maintains communications with the rest of the body
through the spinal cord. The spinal cord is continuous from
the lower end of the brain. The brain both receives impulses
and transmits orders through the spinal cord and out to the
peripheral muscles and organs. These impulses travel to and
from the organs via thirty one pairs of spinal nerves.
The cerebrum occupies most of the cranial cavity. It is highly
folded or convoluted. The cerebrum is concerned with
the higher brain activities such as thinking, memory, logic,
judgement, reasoning and sensation.
The outer surface of the cerebrum is made up of grey matter.
Inside, it is made up of white matter.
Frontal Lobe
Parietal Lobe
Cerebrum
Occipital Lobe
Cerebellum
Glossary
Brain Stem
Temporal
Lobe
Spinal Cord
Term
Definition
Mening
Membrane. Spinal meningitis is
inflammation of the membranes in the
spinal cord
Soma
Body. This can mean the whole body or the
control centre of a cell, for example, the
soma of a nerve cell or neuron. Somatalgia
means body pain
Ventricul
Cavity. There are ventricles/small cavities in
the brain and the spinal cord
Gram
Record/write. Encephalogram is a record of
the electrical activity of the brain
Co, Con
Together/with
En, Em
Within/in. Encephal means in the head
Both the brain and the spinal cord are amply protected from
injury. The brain is protected by the skull, whilst the spinal cord
is protected by the vertebrae of the vertebral column.
In addition, both are also cushioned by the cerebrospinal fluid that
circulates continuously throughout the central nervous system.
The cerebrospinal fluid circulates through a canal in the spinal
cord, the ventricles/cavities in the brain and between the
CNS membranes.
The cerebrospinal fluid is produced in the ventricles of the brain
and circulates throughout the brain, surrounding it on all sides.
It acts as a cushion to protect against shock or trauma.
The spinal cord is suspended in a tube of cerebrospinal fluid.
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Membranes/meninges of the central nervous
system
The meninges are the three membranes that envelop the CNS.
They aid in supporting and protecting the brain and spinal cord.
Neurons that carry impulses from the brain and the spinal cord, for
example glands and muscles, are known as efferent/motor neurons.
They are composed of white, fibrous connective tissue.
If you put your hand on something hot, the afferent/sensory
neurons tell your brain that it is hot. The brain then passes the
message to the efferent/motor neurons to move your hand.
The three membranes are:Membrane
Description
Dura mater
The outermost membrane. It is the
toughest and most fibrous of the three. It
separates the brain from the bones of the
cranial cavity
Pia mater
Thin, compact, filmy membrane that lies
directly on the surface of the brain. It is
highly vascular and supplies blood to the
CNS
Arachnoid
The middle of the three meninges. Almost
web-like in nature. Cerebrospinal fluid can
be found circulating under this layer in the
sub-arachnoid space
The spinal column also has the three meninges; dura mater,
pia mater and arachnoid. The cerebrospinal fluid flows through
a hollow space that runs down the centre of the spinal cord
known as the central canal.
In the spinal cord, the inner matter is grey and the outer matter
is white (the opposite way around to the brain).
The axon is surrounded by a coat of lipids (fats) and a protein
called myelin. The myelin acts as an insulator. All of the nerves
outside of the brain or spinal cord are enclosed within this
myelin sheath
Neurons inside the CNS have naked axons without a myelin
sheath.
Brachial Plexus
Cerebellum
Musculocutaneous
Nerve
Median Nerve
Iliohypogastric Nerve
Subcostal Nerve
Obturator Nerve
Ulnar Nerve
Lumbar Plexus
Sacral Plexus
Femoral Nerve
Pudendal Nerve
Sciatic Nerve
A soma
Common Peroneal Nerve
An axon
Deep Peroneal Nerve
Dendrites
These carry nerve impulses toward the body of the neuron from
the synapse.
Intercostal Nerves
Genitofemoral Nerve
The specialised cells of the nervous system are called neurons.
They consist of:
Of varying length, it conducts electrical impulses away from the
neuron’s soma
Spinal Cord
Radial Nerve
Nerves
A cell body that contains the nucleus
Brain
Superficial Peroneal Nerve
Muscular branches
of Femoral Nerve
Saphenous Nerve
Tibial Nerve
Normally, the electrical impulses or messages that travel along a
neuron pass only in one direction.
Neurons that carry impulses from the receptors, for example
eyes and ears, to the brain and the spinal cord are known as
afferent/sensory neurons.
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Herpes zoster (shingles)
This is a condition caused by an infection that follows normal
nerve pathways.
It is characterised by small blisters or vesicles on the skin.
Shingles is associated with a run-down condition and rarely
occurs in robust people.
It is treated by Zovirax/Acyclovir which can be taken in the form
of tablets or used as a cream to put on the rash.
Herpes zoster is not life threatening.
Spinal injury
If an injury occurs to the spinal cord, there can be serious
problems. Injury can imperil any, or all of its functions.
Treatments for epilepsy are:
l
Phenytoin (epanutin)
l
Carbamazepine (tegretol)
l
Sodium valproate (epilim)
It is important that the level of the drug is monitored in the
blood. Too little can result in the fits continuing to occur and
too much will result in toxicity.
An electroencephalogram (EEG) is a test which will show the
electrical activity of the brain and reveal any excessive/abnormal
activity.
There are also other forms of epilepsy:
If the spinal cord is injured, that part of the cord above the
injury will continue to transmit and receive impulses to and from
the brain. Areas below the injury will usually cease to function.
Form
Cause
Focal
The site and extent of the neurological damage will determine
the degree of paralysis. The degree of recovery will denote the
ultimate prognosis.
Due to abnormal electrical impulses in the
brain
Secondary
Due to brain damage which may be caused
by a tumour, stroke, alcohol, etc
Epilepsy
Epilepsy is a functional nervous disorder arising from excessive
electrical activity in the brain.
The excessive electrical activity results in intermittent
disturbances of movement, sensation and/or consciousness.
Idiopathic epilepsy
While these are less common forms of epilepsy, both are lifethreatening and must be identified.
Multiple sclerosis
Multiple sclerosis is caused by the degeneration of the axon’s
myelin sheath.
This is the most common form of epilepsy. It usually occurs in
childhood or adolescence. Seizures occur without any apparent
organic disease of the brain.
If a nerve becomes demyelinated, the messages to and from
the brain can’t get through. Both sensory and motor nerves are
affected.
There are two forms of idiopathic epilepsy.
Demyelination can be found in many areas of the central
nervous system at the same time. The symptoms, therefore, can
be many and varied.
Form
Description
Major epilepsy/
grand mal
These attacks consist of convulsions and
loss of consciousness. During convulsions,
the tongue may be bitten and joints
dislocated.
Some symptoms are:
l
Impaired reflexes
Petit mal attacks always begin in childhood.
They are characterised by clouding of
consciousness for as long as thirty seconds.
The person may stare blankly or blink and
objects may drop from the hands but he or
she doesn’t fall.
l
Weakness
l
Tiredness
l
Numbness
l
Giddiness and nausea
l
Sight disorders
Minor epilepsy/
petit mal
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l
Ataxia (loss of control over voluntary movements)
l
Chronic quadriplegia (paralysis of all four limbs due to
disease in the spinal column)
Nerve Cell
Multiple sclerosis (MS) is difficult to diagnose. Doctors are
sometimes reluctant to diagnose MS as the symptoms could
have other causes and misdiagnosis could have a psychological
impact on the patient. The following methods are used to test
for MS:
Method
Description
Lumbar
puncture
Cerebrospinal fluid is extracted and the
protein levels tested. A rise in protein
suggests an attack of MS
Visual evoked
responses
Electrodes are fixed to the back of the
patient’s head and lights are shone into their
eyes. The visual evoked responses will be
abnormal if the patient is suffering from MS
Magnetic
resonance
imaging (MRI)
The patient is put in the scanning machine
and pictures showing slices of the brain
reveal widespread lesions of MS
Normal Myelin
Nerve Fiber
Muscle Fiber
Damaged Myelin
(Plaques)
Signal from
brain is blocked
because of
damaged Myelin
Multiple sclerosis is generally a progressive disorder. Its course,
following the initial symptoms, is difficult to predict. In some cases
there may be long periods of remission during which signs and
symptoms either decrease or disappear altogether for some years.
There is no cure for multiple sclerosis, but some of the
treatments include:
l
Adrenocorticotrophic hormone (ACTH). When injected, this
may bring about a slight improvement. It is a steroid, so it is
not a long term cure.
l
Complete rest during bad spells
l
Physiotherapy and exercises to improve co-ordination
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Mental Illness
Mental disorders can be classified under two headings:
Classification
Description
Organic
These disorders are caused by, or associated
with, disease of the brain tissue. An
example of an organic disorder is a tumour
Functional
There is no clear physical cause for
these disorders. They can result from an
individual’s inability to adapt to his/her
environment
Organic mental illness
Organic mental disorders are those caused by or associated
with disease of the brain tissue. They may be acute, chronic or
congenital.
Classification
Description
Organic acute
Acute organic brain disease is due to
infection, trauma or tumour
Organic chronic
Chronic organic brain disease can be due to
blood clots from the neck arteries. It occurs
in the elderly and is usually irreversible.
Chronic organic brain diseases include senile
dementia and alzheimer’s disease
Chronic
congenital
Children born with brain damage such as
Downs Syndrome may have difficulty with
gait and speech. This is often accompanied
by mental impairment
Functional mental illness
Some people are more prone to functional mental illness than
others. Psychiatrists have put forward some reasons for this.
Various personality types are identified as being at risk.
Examples are:
Personality type
Definition
Obsessive
The person is compulsive, a perfectionist,
unable to relax
Hysterical
The person is excitable, emotional
Inadequate
The person has chronic dependence on
others
Paranoid
The person is hypersensitive, suspicious
The two main areas of functional disorder are psychoneurosis
and psychosis.
Psychoneurosis
This refers to a group of disorders involving disturbed emotional
responses, but lacking gross impairment of judgement.
The person is aware (generally) that something is wrong and
their reasoning is not impaired.
Psychoneurosis is often due to circumstances such as
bereavement, divorce, moving home, etc.
It is a reactive disorder. It can present itself in several ways:
Reaction
Description
Anxiety neurosis
Intense prolonged anxiety, depression,
nausea and insomnia
Phobic reactions
Unrealistic fears concerning particular
situations or aspects, for example, fear
of snakes, cancer phobia, etc
l
Faulty home environment (for example, an alcoholic father)
l
History of mental illness in a parent
l
Only child
These are generally reactive disorders.
l
Only boy in a family of girls
Psychosis
The human personality is the basis for all functional mental
disorders. It develops from the person’s genetic composition
and the environment to which he/she is exposed, particularly in
childhood.
When there are defects in the personality development,
disorders can occur.
Obsessive
Persistent recurrence of irrational acts or
compulsive neurosis thoughts
In psychotics, the disturbance of the mind is so great there may be
a disintegration of the personality. They are unaware of anything
being wrong and lose touch with reality. During acute attacks,
odd behaviour occurs. This condition is generally not a reaction to
circumstances and frequently no external cause can be identified.
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Psychosis can present itself in several ways.
Psychotic group
Description
Manic
depressive
psychosis
Main symptoms are elation (excitement),
talkative, tireless etc. There may also be
bouts of deep depression (bi-polar disorder)
Melancholia
Severe state of depression which occurs
after the age of 45. Symptoms are
weeping, pessimism, irritability etc
Schizophrenia
Symptoms are delusions, hallucinations
etc. Schizophrenia means split personality.
The person has a tendency to withdraw
from reality. Thought problems and
disorientation are also characteristic
Alcoholic
psychoses
A group of disorders caused by alcoholic
abuse. They can include symptoms
like delirium, convulsions, terrifying
hallucinations and memory loss
Pathologic
intoxication
Affects people who only drink moderate
amounts of alcohol. It causes a confused,
disorientated state with subsequent
amnesia or memory loss.
Methods to investigate whether a patient is suffering from
psychosis are as follows:
Method
Description
Consultation
A doctor talks to the patient to
ascertain their current mental state.
A psychiatrist may be consulted
Electroencephalogram
(EEG)
This will show the electrical activity
of the brain, and reveal any excessive
or abnormal activity. This is only used
occasionally
People in some psychotic groups have a high suicide rate.
Treatments for this include
l
Hypnotics (sleeping tablets)
l
Anti-depressants
l
Anxiolytics
These drugs can give relief and control of symptoms. However,
some may be addictive and some of the stronger drugs for
psychosis may produce side effects. Other treatments include:
l
Electro-convulsive therapy (ECT). Electrodes are placed on
the head and electric waves are passed through the brain to
treat intractable depression
l
Hospitalisation
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Musculoskeletal System
1.skull
1
2
3
4
5
2.orbit
3.maxilla
4.mandible
5. clavicle (collar bone)
6. scapula (shoulder blade)
17
6
7
16
8
11
13
7.ribs
9
8.humerus
10
9.sternum
12
14
15
10.vertebral column
11.radius
12.pelvis
13.ulna
14.sacrum
18
15.acetabulum
16.carpal bones
19
20
21
17.phalanges
18.femur (thigh bone)
19.patella (knee cap)
20.tibia
21.fibula
22.tarsal bones
22
23.phalanges
23
The skeleton is the framework of the body and provides the
shape, support and protection for the internal organs.
The skeleton is made up of cartilage, joints and bones;
attached are ligaments, tendons and muscles.
As the body develops cartilage is replaced by bones although
some cartilage remains at the end of long bones, joints and
other parts of the skeleton. The elasticity given by cartilage
allows the bones to have an amount of flexibility and also
protects the bones.
The joints are where bones meet and enable the skeleton to
move. They are encased by connective tissue which provides
strength and protection. Bones are bound together with
ligaments which give strength to the joints. Muscles are
attached to the bones with connective tissue known as tendons.
The skeleton consists of 206 bones, the axis being the spine
(vertebral column). The skull rests on the upper end of the
spine and the pelvis is attached to the lower end. The shoulder
girdle consists of the shoulder blades (scapulas) and collar bones
(clavicles) and provides attachment for the arm bones. The leg
bones are attached to the pelvis.
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The Skull
The bones of the skull are divided into two sections, the cranial
skull and the facial skull.
The brain is protected and enclosed by the cranial skull which
consists of a roof and a base.
l
At the base of the skull there is an opening which provides
passages for blood vessels, cranial nerves and the spinal cord.
The coccyx (known as the tailbone) is the end of the spine
The Rib Cage
The Spine
7
4
5
The sacrum consists of 5 vertebrae in children but fuse
naturally to become one single bone which is situated
between the hip bones
The vertebrae are linked by discs of cartilage known as the
intervertebral discs; they provide the spine with support and
flexibility and act as shock absorbers.
The facial skull protects the nasal, oral, orbital and pharyngeal
cavities.
1
l
6
2
8
The rib cage is formed by the thorax bones and provides
protection for the heart, lungs and other organs. The thorax
consists of 12 thoracic vertebrae which provide attachment for
the 12 pairs of ribs. Between each of the ribs are gaps known
as intercostals spaces, which contain muscles, nerves and
blood vessels.
The Shoulder Girdle and Arm
The shoulder girdle contains two bones, the paired clavicles
(collar bones) and the scapulas (shoulder blades). Each arm
contains 30 bones.
3
9
l
Shoulder Girdle: the clavicle joins the sternum at the front of
the neck and joins the scapula laterally. The scapula forms
the rear part of the shoulder girdle.
l
Arm: the arm starts with the humerus followed by the
forearm bones which consist of the ulna and radius.
l
Wrist and Hand: they are made up of the following bones:
8 carpal bones of the wrist, 5 metacarpal bones of the palm
and 14 finger bones or phalanges (3 for each finger and 2
for each thumb).
10
11
1. cervical vertebra
7. cervical vertebrae
2. dorsal (thoracic) vertebra
8. dorsal (thoracic) vertebrae
3. lumbar vertebra
9. lumbar vertebrae
4. body
10.sacrum
5. opening for spinal cord
11.coccyx
6.arch
The spine (vertebral column) is a curved column of individual bones
or vertebrae and they are named in relation to where they are
situated on the spinal column. In infancy there are 33 vertebrae in
the spine but due to natural fusion, by adulthood there are only 26.
1
The vertebrae are named in relation to where they are situated
on the spinal column.
l
l
l
The cervical spine consists of 7 vertebrae in the neck
The thoracic spine consists of 12 vertebrae where the ends
of the ribs are attached
The lumbar spine consists of 5 vertebrae in the lower back
2
3
1.radius
4
2.ulna
3. carpal bones
5
4. metacarpal bones
5.phalanges
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Pelvic Girdle and Leg
The pelvic girdle provides a supportive frame and protects the
urinary bladder, reproductive organs and other internal organs
and allows for weight transfer between from the spine to the
lower limbs. It is formed by the hip bones on either side, joined
with the triangular curved sacrum and the coccyx posteriorly.
The pubis forms the front part of the hip bones and each hip
bone contains a deep cup into which the head of the thigh
bone (femur) fits.
The leg consists of the following bones:
l
Femur (thigh bone)
l
Patella (kneecap)
l
Tibia or shine bone
l
Fibula
l
Tarsal bones (foot)
l
Metatarsal bones (sole of the foot)
l
Phalanges (toe)
Joints
Joints are junctions between the bones and there are 3 types:
l
Fibrous joints; they allow little or no movement
l
Cartilaginous joints; allow limited movement
l
Synovial joints; allow the greatest range of movement
There are over 100 different types of arthritis but the most
important are:
l
Osteoarthritis
l
Rheumatoid Arthritis
l
Sero-negative spondyloarthritides: Ankylosing
spondylitis, reactive arthritis and Reiter’s disease,
psoriatic arthritis, arthritis complication bowel disease
l
Septic Arthritis
l
Gouty Arthritis
Arthritis may involve one joint (monoarthritis), a few joints
(oligoarthritis) or many joints (polyarthritis).
It can be the main feature of a disease (rheumatoid arthritis), or
it may be a secondary feature of a systemic illness (inflammatory
bowel disease).
It can lead to deformity or destruction of involved joints and
this often results in impairment of function, both in terms of
activities of daily living and occupational performance.
Some forms of arthritis are unremitting (chronic continuous disease)
and lead to permanent disability, while others may be associated
with periods of relatively unimpaired function. Occasionally only
one acute episode occurs with subsequent remission.
The severity of arthritis may be classified as mild, moderate or
severe as shown below.
Mild
Minimal joint pain and swelling, no
hospitalisation, no impairment of
activities of daily living. Symptoms
may be intermittent or continuous
but of low severity. Treatment usually
limited to aspirin or non-steroidal
anti-inflammatory drugs
Moderate
More extensive joint involvement,
rare hospitalisation, minimal
impairments of activities of daily
living. Symptoms are continuous but
with slow deterioration.
Severe
Progressive and active disease with
significant disability and frequent
hospitalisation. Requires assistance
with activities of daily living.
Muscle
Muscle fibres found in the skeletal muscle are elongated,
threadlike cells, which are also described as striated muscle (due
to the striped appearance under a microscope).
Muscles are connected to the bones and they lie across a joint
with one end attached to the bone on either side.
Arthritis
Arthritis is a non-specific term describing disease affecting one
or more components of a joint, but usually with accompanying
inflammation.
An arthropathy is an abnormal painful joint which may or may
not be inflamed.
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Although severity is important the joints affected are also
significant. They may be weight-bearing (hips and knees) or
needed in carrying out tasks (hands) and therefore may affect
the ability to perform an occupation.
Back Pain
Related terms:
l
Cervical disc disease
l
Low back pain
l
Lumbago
l
Cervical spine pain
The back is a complex structure and vulnerable to numerous
disease processes giving rise to morbidity. Back pain is a
symptom which may restrict movement and function and is a
very common condition.
Over 90% of back disorders are mechanical and back problems
are often precipitated by injury and aggravated by obesity, weak
muscles and poor posture.
Mechanical back disorders:
There are increased mortality and morbidity risks associated
with chronic back pain. These are usually depression, suicide,
accidents, excessive use of drugs and or alcohol. If the back pain
is poorly controlled there can be a greater risk of depression
compared with the general population. Depression and suicidal
thinking are increased in those with higher levels of pain and
higher levels of pain related disability.
Back pain can be acute or chronic
Acute
Intermittent pain, disability and
intolerance to activity lasting less
than 3 months with complete
resolution of symptoms and a return
to normal activities
Chronic
Constant pain, disability and
intolerance to activity lasting more
than 3 months without resolution
of symptoms and a continuing
restriction of normal activities.
Cervical Spondylosis
A degenerative process in the cervical spine, which results in
narrowing of the spinal canal and nerve root compression.
l
Cervical disc disease
l
Intervertebral disc prolapse
l
Sciatica
l
Thoracic spine pain
Lumbar Stenosis
l
Lumbar spondylosis
l
Spondylolysis
Narrowing of the lumbar spinal canal which may result in
neurological signs and symptoms of the spinal cord or pain in
the legs on walking.
Non mechanical back disorders:
l
Fractures
l
Spondyloarthritis
l
Infections
l
Malignancies
The symptoms and clinical findings in back pain are poorly
correlated. In over 80% of patients, pain is non-specific with only
a small percentage having a definite cause for their back pain.
It is an age related degenerative condition and can be
aggravated by trauma or arthritis.
Whiplash
Also known as post traumatic neck pain, whiplash is forced
flexion-extension injury to the neck. It is typically caused by
automobile collisions.
The symptoms of whiplash can be delayed for up to 24 hours
after an accident and the usual symptoms are increasing pain
and stiffness in the neck shoulders and sometimes the arms.
There may be some tingling present. It is possible to nod the
head but movements of the rest of the neck are painful.
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Knee Disorders
Hip Disorders
The knee is a major weight bearing joint and is vulnerable to
injury. It is subject to disease processes which include fracture,
osteoarthritis and chodromalacia (painful softening of the
cartilage of the patella).
The hip is a major weight bearing joint and subject to many
conditions including fracture, dislocation, osteoarthritis,
rheumatoid arthritis and bone diseases.
Tearing of the knee ligaments and or cartilage is common in
younger adults involved in sporting pastimes.
Loosening of the knee ligaments produce instability following an
injury. Locking of the knee is usually suggestive of a loose body
within the joint with cartilage rupture often being the cause.
1
2
1
2
4
7
3
3
5
6
8
9
10
1.acetabulum
11
2.synovial fluid
3.femur
Hip disorders commonly cause groin pain and low back pain
and mobility may be impaired.
Surgery such as total hip replacement is common usually after a
fracture or due to severe osteoarthritis.
1.skin
2.femur
3. joint space
4.muscle
5. knee cap (patella)
6. pre-patellar bursa
7. articular cartilage
8. synovial membrane
9.bursa
10.tibia
11.muscle
Shoulder Disorders
The shoulder joint has a wide range of movement and is held
in position by a wide array of muscles and the joint capsule
(together these are known as the rotator cuff).
There are numerous labels for the various types of shoulder
disorder but those listed below are the more common:
l
Frozen shoulder – pain or stiffness with restricted movement
l
Torn rotator cuff – an injury with minimal trauma or preexisting inflammation (eg rheumatoid arthritis)
l
Recurrent shoulder dislocation
l
Arthritis of the shoulder
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Osteoporosis
Osteoporosis is a disorder which results in a reduction of the bone
mass and deterioration of the bone leading to fragility fractures.
The skeleton reaches peak bone mass and strength at about
30 years of age, after which it slowly declines. Peak bone
mass is determined by a number of factors including gender
(around 25% higher in men than women), genetics, nutrition
an exercise. Following the menopause the rate of loss in
women increases. A high peak bone mass reduces chances of
osteoporosis.
Most causes of osteoporosis are post-menopausal or senile, but
may be secondary to a number of diseases including:
l
Anorexia nervosa
l
Endocrine disorders including Type 1 diabetes
l
Multiple myeloma
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Tumours
A benign tumour is not life threatening in itself and treatment
may not be required. However, it is sometimes necessary to
surgically remove the tumour.
The decision to do this would depend on a number of factors,
including the following:
A tumour is an abnormal mass of tissue which grows at a
different rate from the surrounding normal tissue. The word
tumour can literally mean any swelling, but by convention it is
taken to mean abnormal growth.
Glossary
Factor
Reason
Site
For cosmetic reasons
Size
A growth can cause pressure on surrounding
tissue or interfere with hormone production
Predisposition
to malignant
change
A tumour that changes in nature and starts
to spread could be fatal
Malignant tumours
A malignant tumour is also known as a cancer or carcinoma.
Malignant tumours are far more serious than benign tumours.
They grow rapidly and persistently and metastasise via the blood
stream and the lymphatic system to form secondary tumours in
other sites. These secondary tumours grow in a similar way. If
left untreated, malignant tumours can be fatal.
Term
Definition
Adeno
Gland
Myo
Muscle
Oma
Tumour
Fibro
Fibre
Melan
Black
l
What type of tumour it is (nature of the tumour)
Leuk, leuc
White
l
Where in the body it is located (site)
Cyte
Cell
l
Blast
Bud, immature cell
When the tumour was first diagnosed
Carci
Malignant
l
Date and details of any treatment given
Cyst
Sac, bladder. Used on its own, cyst means a
hollow tumour containing fluid or soft material
Also, two other factors must be taken into consideration:
Fibroids
Tumours, particularly common in the uterus
Adenoma
To medically assess any malignant growth, it is always necessary
to establish all the information. For example:
l
Staging (the physical extent of the disease)
Tumour composed of gland tissue
l
Prognosis (prospects for treatment and recovery in the future)
Melanoma
Tumour containing black pigment
Metastasise
Spread
The term staging is used to describe the extent to which a
malignant disease has spread throughout the body, i.e. whether it
is confined to one primary site and, if not, how far it has extended.
Benign tumours
Benign tumours are also known as simple or innocent tumours.
They are localised growths which, as a rule, grow slowly. They
do not generally infiltrate surrounding organs or tissues and do
not metastasise to other sites in the body.
You need to know the staging of a disease before any
prognosis can be reached. Localised disease would usually have
a better prognosis than widespread disease.
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Staging classification system
Stage I
Entirely
localised
Disease is restricted to the organ
of origin
Stage II
Limited
invasion
Some invasion of adjacent tissue
Stage III
Extensive
invasion
Involvement of nearby lymph
nodes
Distant
metastases
Disease has spread to distant sites
Stage IV
The general staging system is not specific enough for certain
types of cancer and special staging systems are used for these:
Cancer type
Staging system used
Colorectal cancer
Dukes
Bladder tumour
Marshall
Melanoma
Clark
Special staging systems also exist for some other malignant
diseases including cancer of the uterine cervix, cancer of the
lymph nodes (Hodgkin’s disease) and testicular cancer.
The severity of each of the numbered stages in any of these
classification systems may vary according to the nature of the
tumour and location of the primary site.
In addition, the staging of an individual case may alter during
the course of investigation and treatment, either because the
disease progresses or because more sophisticated techniques are
subsequently used to assess it.
Tumour types may also be classified according to the nature of
their constituent cells and the degree of malignancy indicated
by this.
Normally, this will be self evident from the name of the tumour
itself and this, in conjunction with the site of the tumour will
also help to determine the final rating applied.
A well differentiated tumour is a tumour which grows relatively
slowly and in a well defined shape.
A poorly differentiated tumour means the tumour cells are
so malignant that it is impossible to determine the normal
tissue type from which the tumour is derived. This is a poor
prognostic indicator because poorly differentiated tumours are
more likely to be locally aggressive and metastasise than welldifferentiated tumours.
Once the tumour type and staging have been identified, the
prognosis or prospects for treatment and recovery can be
assessed.
Factors taken into consideration in the prognosis include:
Factor
Implications
Effectiveness of
treatment
Has the tumour been completely
eradicated or will it recur?
Degree of
malignancy
May depend on the type of tumour cells
and what part of the body is affected
Staging
The more widespread the disease, the
more difficult it is to locate and treat
Blood tests
Substances in the blood indicate that
malignant cells are present, perhaps
even after treatment
The treatments used for malignant tumours include the following:
Surgery
The surgical removal of tumour tissue has always been the main
treatment for malignant growths. It can be a cure, but especially
where the disease is extensive, surgery can only offer temporary
relief. In some cases, it is purely palliative i.e. just to ease suffering.
The surgery can deal effectively with the primary tumour, but
undetected secondary spread (sometimes microscopic) may be
left behind. It is also possible that surgery may release tumour
cells into the bloodstream, causing secondary growths elsewhere.
Radiotherapy
Malignant cells can be destroyed by radiation. A radio-active
beam is directed at a target tumour, which causes it to shrink. It
can definitely be a cure for a limited number of tumours, but in
cases of extensive malignancy, it may only afford temporary relief.
Great precision is required of the radiotherapist to minimise the
destruction of healthy cells.
Radiotherapy may be used in conjunction with other treatments,
such as surgery or chemotherapy.
Chemotherapy
The disease is treated by cytoxic drugs, which inhibit
cell reproduction.
Because they are administered via the blood stream, their
effects are far-reaching. The drugs are toxic to both malignant
and healthy cells and there may be side-effects, such as sickness
and hair loss.
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This type of treatment has proved very effective for leukaemia
and tumours of the reproductive system.
Sometimes a combination of surgery, radiotherapy and
chemotherapy may be used.
Endocrine therapy
Some tumours depend on hormones for growth. In this therapy,
various treatments are given to control the hormones that are
stimulating tumour growth.
The four most common methods of investigation for malignant
tumours are:
Method
Definition
X-rays
The procedure varies for each organ
Biopsy
A small sample of the tissue is removed for
analysis
Radio-isotope
scanning
Procedure varies according to the organ
involved
Blood tests
Biological markers secreted by tumours are
identified in the blood
Biological markers
One of the biggest problems in investigating malignant disease
is detecting secondary spread. A great breakthrough in the
treatment of cancer therefore, has been the discovery that some
tumours release certain substances into the blood.
If these substances (biological markers) are present when the blood
is tested, a tumour is also present. If biological marker levels remain
high after treatment, this indicates that malignant cells are still
present, or that there is a recurrence of the disease. By testing the
blood for biological markers, minute quantities of tumour cells can
be detected, which other methods of investigation can’t identify.
Carcinoma of the cervix
The results of smear tests are classified according to the Cervical
Intraepithelial Neoplasia (CIN) system.
This is a way of describing the amount of dysplasia (abnormal
development) of the cells.
Smear tests are classified as:
Classification
Definition
CIN1
Mild dysplasia
CIN2
Moderate dysplasia
CIN3
Severe dysplasia or carcinoma in situ
(i.e. no invasion of surrounding tissue)
When test results show CIN1 or CIN2, follow up smears are
recommended, but no treatment is required, since many cases
return to normal.
Findings of CIN3 requires further investigation and treatment,
perhaps by cryosurgery (freezing the affected area) or laser, and
then repeat smears to check that all malignant cells have been
eradicated.
An even more severe condition than CIN3 is invasive carcinoma,
which has another classification system of its own.
A tumour of this sort requires more extensive treatment,
including radiotherapy and/or hysterectomy. Chemotherapy has
so far not proved successful in treating carcinoma of the cervix.
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Hodgkin’s disease
Cervical Nodes
Lymph Vessels
Axillary Nodes
Lymph Vessels
Inguinal Nodes
Lymph Vessels
Hodgkin’s disease is a condition in which the lymphatic glands
all over the body become infiltrated with malignant cells.
The person may suffer weight loss, night sweats, unexplained
fever and anaemia.
When the disease is localised, the treatment is radiotherapy. For
more widespread disease, chemotherapy or a combination of
both radiotherapy and chemotherapy is used.
The actual prognosis of this disease will depend on investigation
(including biopsy) into the nature of the tumour and the staging
of the disease.
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Build
Obese people are more prone to heart disease, strokes, high
blood pressure, diabetes, chronic depression and many other life
threatening conditions.
The key obesity measure is BMI (Body Mass Index). The BMI
compares weight with height, irrespective of sex. It is calculated
by dividing weight in kilos by height in metres squared (m2).
BMI is an accurate reflection of body fat percentage in the
majority of the adult population.
A typical classification of BMI is:
Underweight
Underweight may be an indication of malnutrition but more
usually is either a normal body state in an otherwise healthy
individual.
The most immediate problem with underweight is that it might
be secondary to, and/or symptomatic of, an underlying disease.
Unexplained weight loss requires professional medical diagnosis.
Other causes include anorexia, most often found in young
women.
BMI
Definition
Complications of underweight include increased risk of
infections, falls, fractures and osteoprosis.
>17
Underweight
Obesity
18-25
Healthy
26-30
Overweight
31-35
Obese
36-40
severely obese
40>
Morbidly obese
For Income Protection this would be 38>
Obesity is a medical condition in which excess body fat has
accumulated to the extent that it may have an adverse effect
on health, leading to reduced life expectancy. Obesity is a
leading preventable cause of death worldwide, with increasing
prevalence in adults and children. Authorities have often cited it
as one of the most serious public health problems of the
21st century.
Height (meters)
110
132
154
The prime cause of obesity is excessive calorific intake - often
combined with a sedentary lifestyle. Genetics may have a role,
as obesity often runs in families. Occasionally, obesity may be
due to another medical condition or the treatment of another
condition.
Weight (pounds)
176
198
220
242
264
286
308
330
2.00
6’7
1.90
6’3
1.80
5’11
1.70
5’7
1.60
5’3
1.50
4’11
50
60
70
80
90
100
110
120
130
140
Height (feet and inches)
BMI is sometimes criticised as a crude measure of obesity.
Though it does not actually measure the percentage of body
fat, it is a useful tool to estimate a healthy body weight based
on how tall a person is. Due to its ease of measurement and
calculation, it is the most widely used diagnostic tool to identify
weight problems. As the acceptable weight range will usually
include moderately overweight, the limitations of BMI for
applicants are of little concern in life assurance.
150
Weight (kilograms)
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Medical risks of obesity include:
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High blood pressure
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Ischemic heart disease, angina and myocardial infarction
(heart attacks)
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Congestive cardiac failure
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Raised cholesterol
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Deep vein thrombosis/pulmonary embolism
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Diabetes mellitus
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Strokes
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Gout
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Osteoarthritis
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Low back pain
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Fatty liver disease
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Chronic renal failure
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Gallstones
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Asthma
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Cancer (breast, ovarian, oesophageal, colorectal, liver,
pancreatic, gallbladder, stomach, endometrial, cervical,
prostate, kidney)
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Non-Hodgkin’s lymphoma
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Multiple myeloma
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Obstructive sleep apnoea
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Polycystic ovarian syndrome
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Gastro-oesophageal disease
Mortality risk varies with BMI. Obesity on average reduces life
expectancy by six to seven years. A BMI of 30–35 reduces life
expectancy by two to four years while severe obesity (BMI 40>)
reduces life expectancy by twenty years for men and five years
for women.
Key points for life insurance
Obesity is often progressive with age. A younger obese life
therefore, may be rated more severely than an older life with
the same BMI.
Moderate overweight is often accepted at standard terms.
Significantly overweight applicants will be subject to a heavy
premium loading. They may be declined if their BMI exceeds a
certain threshold or other risk factors are present, for example,
a history of angina.
Most underweight lives are acceptable at standard terms,
however very underweight lives may be declined. Underweight
applicants with recent weight loss would be a cause for concern.
Additional points for income protection
insurance
Obesity also has the potential to impact on the customer’s ability
to work and as such, people who work in a more physical job
would be reviewed in more detail than those in a less demanding
role. For example, obesity puts greater strain on joints and
therefore may lead to problems for builders, plumbers etc.
If a customer was significantly overweight we would be likely
to impose a higher loading on their policy, and if severely to
morbidly overweight we would decline to offer cover.
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Smoking
The detrimental effects of smoking on health are well known.
Smoking facts
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On average, each cigarette shortens a smoker’s life by
around 11 minutes
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Smoking reduces life expectancy by seven to eight years
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The number of people under the age of 70 who die from
smoking-related diseases exceeds the total figure for deaths
caused by breast cancer, AIDS, traffic accidents and drug
addiction
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Smokers in their 30s and 40s are five times more likely to
have a heart attack than non-smokers
Why is smoking bad for you?
Cigarettes contain more than 4000 chemical compounds and
at least 400 toxic substances. Burning tobacco releases these
toxins.
l
l
l
l
tar, a carcinogen (substance that causes cancer)
nicotine is addictive and increases cholesterol levels in
your body
carbon monoxide reduces oxygen in the body
Smoke contains several carcinogenic pyrolytic products that
bind to DNA and cause many genetic mutations. There are
over 19 known chemical carcinogens in cigarette smoke.
Implications for life, critical illness and
income protection insurance
l
Smokers pay a higher standard premium. Smoker rates
include anyone who has smoked any form of tobacco within
the 12 months prior to application
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Very high levels of tobacco consumption may lead to a
loading on top of the smoker rates.
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Smoking may increase ratings for conditions that it is known
to exacerbate or reduce the effectiveness of treatment
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An accurate and reliable test for the presence of cotinine (a
by product of nicotine) is routinely used by insurers to test
declared non-smokers
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Failure to correctly declare as a smoker will usually be treated
as deliberate non-disclosure which would therefore result in
the non-payment of a claim.
What are the health implications?
Cancer: The link between smoking and lung cancer is the most
well known health risk - ninety percent of lung cancer cases
are due to smoking. Smoking is also the usual cause of mouth
cancer. Several other types of cancer are more frequently found
in smokers – oesophagus, bladder, kidney, pancreas and cervix.
Cardiovascular disease. This is the main cause of death due to
smoking. Smoking accelerates the hardening and narrowing
process in your arteries. Hardening of the arteries is a process
that develops over years, when cholesterol and other fats
deposit in the arteries, leaving them narrow, blocked or rigid.
When the arteries narrow (atherosclerosis), blood clots are likely
to form. This in turn leads to an increased risk of heart attacks,
strokes, high blood pressure, kidney failure and gangrene of the
legs.
Chronic obstructive pulmonary disease (COPD) is a collective
term for a group of conditions that block airflow and make
breathing more difficult, such as: emphysema - breathlessness
caused by damage to the air sacs (alveoli) and chronic
bronchitis - coughing with a lot of mucus that continues for
at least three months. Smoking is the most common cause of
COPD and is responsible for 80 per cent of cases.
Other risks include blindness and other eye problems, ulcers,
impotence and teeth loss.
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Alcohol
Alcohol use is a regular and accepted recreation in our society.
However there are risks associated with excess consumption.
Alcohol is a drug, and as such alters a person’s physical and
mental state. Small amounts lead to a sense of wellbeing
and relaxation with a lessening of tension and inhibitions.
Speech slurring and unsteadiness also become evident. Binge
drinking is associated with accidents, violence and crime, as
well as a hangover the next day, with headaches, vomiting and
indigestion. Even though the heavy regular drinker may not
become drunk, damage to the internal organs may still happen.
This increases the risk of liver cirrhosis, stomach ulcers, heart
disease, strokes and some cancers. Alcohol is a depressant and
many heavy drinkers have mental health problems. Alcohol
often contributes to problems with family, relationships, work,
finances and crime.
Implications for life, critical illness and
income protection insurance
l
We ask about usual consumption levels and whether there
has ever been any medical advice to stop or reduce drinking.
l
High level of consumption may lead to a premium increase.
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A history of damaging alcohol abuse where the applicant has
ceased drinking will take into account how long they have
been abstinent. Recent cessation may mean postponement.
Otherwise a loading or standard terms will apply.
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A history of damaging alcohol abuse with continuing alcohol
consumption will lead to an application being declined.
While we often relate alcohol problems with young binge
drinkers or the chronic alcoholics the reality is that we should
be far more worried about the high numbers of middle aged
people who regularly risk damage to their health though their
social and relaxational drinking.
Drinking too much
Excessive levels of consumption can be divided into three broad
categories
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Hazardous drinking.
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Harmful drinking. Frequent or regular binge drinking can
be considered harmful drinking and can lead to long-term
health problems or dependence.
l
Alcohol Dependence. A chemical dependence on alcohol
Effects of excess drinking
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liver/brain/heart damage
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gastritis (inflammation of the stomach lining)
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pancreatitis (inflammation of the pancreas)
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high blood pressure
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cancers
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seizures
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impotence/infertility
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Psychological effects. Long-term heavy drinking can increase
anxiety and cause depression, memory loss and dementia. It
can also lead to sleeping problems, mood-swings, violence
and suicide.
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Drugs
Almost all of us will have taken a mood-altering chemical at
some time or another - i.e. what we call a drug. We’ve drunk
coffee or tea, or had a few glasses of wine or beer. These
are acceptable practices in terms of their health and social
consequences. Some people will also take potentially more
damaging drugs.
Drug abuse means the voluntary abuse of drugs - i.e. where
people choose to do so. This includes people who use illegal
drugs or abuse legal drugs.
Types of Drugs
Stimulants. The most widely abused stimulants are cocaine,
crack (a pure form of cocaine) and amphetamines.
Depressants. These are substances that slow down or depress
the Central Nervous System. Depressant drugs include alcohol,
barbiturates and tranquillisers.
Dependence is more advanced level of abuse where desire for
drugs has become a compulsion. Physical dependence is when
the body comes to need a drug to function normally. If it’s not
taken, unpleasant withdrawal symptoms occur. The only way to
avoid this is to take more drugs.
Analgesics. Analgesics are substances that provides relief
from pain. Mild analgesics, such as aspirin or paracetemol are
relatively harmless. Analgesic drugs of abuse are far stronger
than this and are all powerful pain killers. Some are refined
from an extract obtained from opium poppies (Papaver
somniferum) and are classed as “opiates” and some are
produced by chemical synthesis.
Psychological dependence is when an individual comes to rely
on a drug to supply good feelings - such as relaxation,
self-confidence, self esteem, freedom from anxiety etc.
Opiates include Opium itself, which is the resin obtained from
the seed pod of the opium poppy, along with Morphine, Heroin
and Codeine.
People abuse drugs for many different reasons:
Synthetic analgesics are manufactured as powders, tablets or
liquids. They include Methadone, Physeptone Pethidine, Diconal
and Palfium
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To avoid feeling bored
l
To fit in with peers
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To increase self-confidence
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To forget about problems
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To relax
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To feel good.
Risks of drug abuse
Risks associated with drug abuse include:
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Loss of control – leading to addiction
l
Risk to personal safety - danger of death or injury by
overdose, accident or aggression.
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Damage to health - including brain damage, liver failure,
mental problems etc.
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Legal consequences - risk of imprisonment, fine and criminal
record.
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Destructive behaviour - that can harm self, family and
friends.
Hallucinogens - or psychedelics - are drugs that affect
a person’s perception of sights, sounds, touch, smell etc.
Some of the stronger hallucinogens can exert a powerful
effect on a drug users thinking and self-awareness.
They include mescaline (found in magic mushrooms)
LSD, MDA (methylenedioxyamphetamine) and Ecstasy
(methylenedioxymethamphetamine - or MDMA).
Implications for life assurance, critical
illness and Income protection
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Any history of drug abuse is cause for concern.
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Ongoing abuse will usually mean any application is declined.
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Consideration of a history of drug abuse will depend on the
types of drug used, the length of abuse and any damage
to health, the length of time since cessation. Any history of
injecting drugs will often need a HIV test.
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Residence and Travel
Travel and Residence
We ask about foreign travel and residence for various reasons;
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Political Instability which includes:
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Premium rates are based on mortality experience of UK lives.
War
l
Overseas, different risk factors come into play which
substantially alter life expectancy, e.g.
Terrorism
–Economic & Social Conditions
–Medical Facilities
–Overseas living conditions can be very different from the
UK and can significantly vary within other countries, e.g.
a white-collar worker in the United Arab Emirates might
enjoy a similar standard of living to that in the UK, while a
UK relief worker stationed in Ethiopia could be far closer
to the indigenous population.
–The quality and availability of medical facilities should
always be considered. An applicant working in a remote
area, inaccessible to local hospitals presents as a more
adverse risk than someone living in a city and close to
medical facilities does.
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Uprising & insurrection
All of which present additional risk of violent death or
disablement
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There are also legislative and tax implications regarding
overseas business
Implications for underwriting
l
Applicants must usually be resident in the UK
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Holidays are usually ignored
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Substantial foreign travel to high risk countries may result in
a loading or even an application being declined
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Past travel to high risk countries for AIDS may mean that we
need a HIV test before acceptance
AIDS represents a significant risk in some regions overseas
not only from sexual transmission but also from infected
needles or contaminated blood products in areas where
screening procedures of medical facilities are inadequate.
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Financial Underwriting
Financial Underwriting can be a complex area but its basic principles
are straightforward and can be summarised as follows:
l
To ensure that the insured or beneficiaries are not put in a
better position by the occurrence of an insured event.
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To minimise the ‘moral’ risk - the effecting of an insurance
policy in itself increases the chance of an insured event
happening. Fraud is rare but not unknown as are murder and
suicide.
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To minimise the risk of lapse and/or early surrender of the
policy by ensuring both that the insurance is appropriate and
the premiums are affordable.
For personal Life and CI financial underwriting is usually minimal
except when cover amounts are very high. The level of cover is
calculated to provide financial security. Such levels depend on
loss of income and liabilities – usually a mortgage. Where levels
of cover are high specific details about income and liabilities
plus details of existing cover will be required – usually by a
financial questionnaire.
For Income Protection some level of financial underwriting is
usually fundamental to the contract. While the aim is to relieve
financial hardship in the event of disability there is the need
to avoid over insurance. There needs to be a clear financial
incentive to return to work.
Business Protection is an underdeveloped market. There are
clear needs in terms of areas like key person insurance and
shareholder protection. But these are a complex, specialised
areas covered in detail elsewhere. Aviva has a dedicated guide
to Business Protection.
Financial underwriting will usually allow the cover as requested
but there may be a need to reduce the cover amount and/or
term. Rarely applications will be declined.
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Aviva Life Services UK Limited. Registered in England No. 2403746 Aviva, Wellington Row, York, YO90 1WR.
Authorised and regulated by the Financial Conduct Authority. Firm Reference Number 145452.
aviva.co.uk
PT15357 04/2017 © Aviva plc
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