We turn now from a general discussion of long-term care insurance to examine genetic testing for Alzheimer’s risk and its role in the long-term care insurance market.
The APOE genetic marker has been consistently shown to be associated with risk of Alzheimer’s disease.13
Because 75 percent of people developing this disease eventually move to a nursing home, this makes APOE a plausible genetic marker to use to identify those at risk of future long-term care use.14
We tested whether APOE genotype independently predicts actual nursing home placements in a community-based sample, the Piedmont Health Survey of the Elderly. Further, we analyzed whether participants in the second REVEAL clinical trial reported being more likely to purchase long-term care insurance upon finding out they had an variant of APOE that increased the risk of Alzheimer’s disease. In this way, we provide evidence of how well APOE predicts actual long-term care use, as well as how a selected sample of consumers respond to receipt of information about their APOE genotype.
The Piedmont Health Survey of the Elderly is a population-based survey of a community cohort of people age sixty-five and older; it is designed to investigate physical, psychological, and social functioning.15
Participants lived in five contiguous counties (one urban, four rural) in the North Central Piedmont region of North Carolina. A baseline interview in 1986–87 was followed by three additional in-person interviews and four telephone interviews; the last in-person interview was in 1996–97. Six years after baseline, blood was drawn from consenting subjects, and APOE genotype was assessed using standard procedures.16
The number of subjects with useable genotyping for this study was 2,089.
We used individual APOE genotype as a predictor of moving to a nursing home from study inception (1986–87 in home interview) until 31 December 2006. People with at least one e2 trait and no e4 trait (n
= 308) were hypothesized to be at low risk for moving to a nursing home; those with at least one e4 trait (n
= 578) were hypothesized to be at high risk; and those with two e3 traits (n
= 1; 113) were hypothesized to have average risk. The group with two e3 traits served as the comparison group in all analyses. People who had one e2 trait and one e4 trait (n
= 90) were excluded from analyses following the normal convention in the literature.17
We also controlled for self-reported age, sex, marital status, and race, and we estimated a logistic regression model that identified the effect of APOE on the likelihood of moving to a nursing home.
The REVEAL study18,19
is a series of multisite randomized clinical trials designed to assess the impact of APOE genotype disclosure on first-degree relatives (that is, adult children, siblings) of people with Alzheimer’s disease. In each of the study protocols, genetic counselors provide education, APOE genotyping, and disease risk information to interested participants, who are then followed up to a year after risk disclosure to determine its psychological and behavioral impact. In the initial trial (n
= 162), we found that people who were told they had at least one e4 trait were more likely than those who did not have an e4 trait to report changes in long-term care insurance after receiving this information.1
We report here on results from the second trial (n = 276, mean age = 58 years), where all participants received APOE genotype information, via the original Extended Protocol (two in-person sessions, mean duration = 76 minutes total) or a more clinically feasible Condensed Protocol (one in-person session, mean duration = 33 minutes total). Participants were asked about their long-term care insurance holdings at baseline; in follow-up, they were asked to describe any changes made in this insurance domain.