What really matters when the life underwriter sees blood pressure differing significantly in people over (versus under) age 65?

The answer is not widely known.

In fact, those who are astute in assessing BP risk have noticed that some mid-life “rules” completely invert in these older persons.

For example, diastolic BP (DBP) is the driver of mortality risk under age 45. Later in life, however, just the opposite is true. Of the 3 BP variables measurable during a routine examination, diastolic finishes dead last (at least when elevated).

In assessing risk in this population, systolic BP (SBP) and pulse pressure (PP) carry the day. Pulse pressure is the difference between the systolic and diastolic readings. For example, if the BP is 140/80, then the PP is 60.

As we age, SBP inches upward while DBP diastolic readings slowly decline, widening the pulse pressure. When the PP gets too wide (prevalent rule of thumb being > 70), it reflects insidious arterial stiffening and bodes unfavorably for both mortality and morbidity.

Older age hypertensive individuals present most often with so-called “isolated systolic hypertension.” ISH is present when SBP is >140 but DBP remains normal. Thus, ISH will often correlate with high PP as this gap widens.

ISH confers extra mortality. The degree of that mortality depends on how high both the systolic BP and pulse pressure get–before they are (hopefully) treated, that is.

In truth, the efficacy of the many widely-used BP drugs is more or less the same. Physicians choose the drug (actually, drugs, since most people with high blood pressure are treated with two drugs, not just one) which in their experience is the best fit for the patient’s circumstances.

As regards perscriptions for geriatric hypertension, 2 points stand out from a life underwriting perspective:

o If 3 drugs are needed, this is likely a worst case scenario.

o If the physician incorporates a nitrate–typically used for angina–specifically into the patient’s blood pressure treatment regimen, this is a clue that elevated PP may also be present

Patient compliance with taking BP drugs as prescribed is the number one risk factor for failure to control elevated readings. Non-compliance is most common at older ages, making this an important focus of underwriting scrutiny. And, this is feasible in underwriting, if the insurer makes use of perscription drug profiles.

The BP risk over age 65 encompasses more than “just” hypertension. There are key implications with low and/or falling BP, which may be a clue to early malfunction during the filling (DBP) or pumping (SBP) phases of the cardiac cycle. Both of these dysfunctional states are precursors of congestive heart failure.

While the subject remains a matter of debate among some hypertensionologists (cardiologists specializing in high blood pressure), there is impressive evidence that the risks associated with blood pressure are–in non-actuarial parlance–J-shaped. This means there is excess risk at both ends of the blood pressure spectrum, with the lowest risk found closer to the middle of the distribution of readings.

This J-shaped mortality phenomenon has been convincingly associated with build, cholesterol and even one’s pattern of alcohol consumption.

Therefore, a strong case could be made that an underweight 65 year old male with significantly low or falling (in the absence of treatment, of course) cholesterol and blood pressure is a far greater risk for at least short duration mortality than a robust fellow with moderately-elevated BP and cholesterol.

The immediate need is for the life insurance industry to raise awareness that the risk significance of blood pressure changes with aging. The industry also needs to to encourage deployment of appropriate guidelines reflecting this reality.

The good money says the industry still had a way to go in making this happen. In consideration of general population aging, greater longevity and growing demands for sizeable cover in this market, these modifications should get top priority.