20: The Aging Traveler

1. Older adults, because of their diminished physiologic reserve, are more vulnerable to most of the hazards facing any traveler.

2. Because exacerbation of chronic illness is a major risk for any traveler, focusing on “disease management and education” in advance of travel is particularly important for older travelers.

3. Any form of travel increases the risk of venous thromboembolism, which can be more serious in older adults.

4. A prior knowledge of resources available to health professionals called to help in a medical emergency during air travel may be lifesaving.

Travel is enjoyed by many and tolerated by some, but is simply a part of modern life. Everyone who travels, however, is subject to certain “risks” inherent in travel. Among them are exposures to unfamiliar climates, foods, illnesses, language and customs, hazards caused by “relaxed” public safety standards, lack of handicap access, crime in unfamiliar settings and risks specific to a particular mode of travel. Problems for elders also increase when stressed by dehydration, temperature extremes, acute illness or exacerbation of chronic illnesses and increased falls risk as a result of such factors as lack of handrails, uneven surfaces or even an unfamiliar hotel room in the middle of the night. Older adults are also affected more by jet lag and this condition, when coupled with confusion in a person with even mild cognitive impairment in an unfamiliar setting can be a formula for adverse events. Anyone who has ever been confused in a busy airport while worrying about how to get to the correct airport gate in time for their flight will realize that any underlying confusion will likely make travel even more stressful. Thus, almost all of the factors that contribute to travel risk are amplified in elder travelers.

Robust data about the demographics of the medical problems of travel are lacking. There are some surveillance systems in place, such as the GeoSentinal Surveillance Network, which aggregates data about infectious diseases worldwide from a network of travel and tropical-medicine clinics on 6 continents. This network may be useful in assessing the likely causes of febrile illness in a returning traveler or understanding infectious disease travel risks based on the location of travel. There are, however, really no comparable entities collecting data about other problems related to travel. Nations usually do not keep information about victims of crime or accidents in formats that allow aggregation of those data and there are many problems assembling international statistics. Many travel-related health problems are never reported and institutions such as hotels and airlines are not in the business of collecting this kind of information. What data we do have indicate that common infections (upper respiratory infections and gastroenteritis) are common and motor vehicle accidents are the most likely traumatic event followed by falls and pedestrian accidents. Less common are health problems resulting from crime, unusual problems resulting from “adventuring,” and incidents arising from civil unrest. The principle that “common things occur commonly” certainly pertains to travel.

Deep venous thrombosis (DVT) and venous thromboembolism (VTE) are common illnesses with an estimated frequency of 1–2 per 1000 individuals. The estimated 28-day mortality for a first episode of VTE in ambulatory persons is around 11%, illustrating the serious nature of this problem. Among the numerous recognized risk factors for DVT and VTE are hypercoagulable states, immobility, cancer, orthopedic problems, and other surgical procedures, but advancing age is an independent risk factor for DVT and VTE. Although it has been recognized for some time, the risk of DVT and VTE incident to travel has been somewhat difficult to quantify. Early studies of “the economy-class syndrome” offered conflicting conclusions about the risk. A recent meta-analysis concluded that the pooled relative risk for VTE in travelers is 2.0 (95% confidence interval [CI], 1.5–2.7). By excluding studies with control participants who were referred for VTE evaluation which led to “referral bias” in the control group, the relative risk for any form of travel was determined to be 2.8 (CI 2.2–3.7). A dose–response relationship was identified with an 18% higher risk of VTE for each 2-hour increase in duration of travel. Of particular interest was a 26% higher risk for every 2 hours of air travel. When we consider the ease and frequency of long distance air travel in today’s world and the factors known to be associated with increased VTE risk without travel, we see that the known increased risk of VTE while travelling should be an important consideration in preparing an older adult for travel. It is appropriate for the clinician to assess the magnitude of the risk in individual patients with the goal of deciding whether a pretravel risk-reduction intervention is warranted. All older travelers will benefit from particular attention to attenuating the modifiable risks of travel such as dehydration, immobility and combating lower extremity venous stasis. Treatment with various forms of anticoagulation should be considered for those at greatest risk. Suggestions include:

1. Low risk (eg, age only, obesity, active inflammation, recent nonorthopedic surgery): encourage frequent ambulation, hydration and perhaps compression stockings.

2. Moderate risk (eg, prior DVT, known venous disease): above plus low-dose aspirin if no contraindications.

3. High risk (eg, recurrent DVT/VTE, hypercoagulable state, malignancy, etc): above plus consideration of low-molecular-weight heparin or the newer oral anticoagulants, such as factor Xa or thrombin inhibitors.

Because advancing age is an independent risk factor for DVT and VTE, many older travelers will likely fall into at least the moderate-risk group.

A number of resources are available to any traveler and to the health professional providing advice to an elder traveler. The U.S. Department of State maintains an excellent website devoted to international travel (http://www.travel.state.gov) focusing on advice about handling difficulties encountered while travelling internationally and highlights areas in the world with particular risks. The Centers for Disease Control and Prevention maintains a website devoted primarily to illness related to and vaccines recommended for international travel (http://wwwnc.cdc.gov/travel), including the well-known “Yellow Book.” The CDC also maintains the very useful “Green Sheet” report from the Vessel Sanitation Program, which lists most international cruise ships and the results of sanitary inspections of those ships (http://wwwn.cdc.gov/inspectionquerytool/inspectiongreensheetrpt.aspx).

It is important for health professionals providing travel advice for older adults to also encourage the traveler to carry with them a listing of their chronic medical problems, a list of their current medications and should ideally include a copy of a recent electrocardiogram. Anyone who has been asked to provide medical care to a confused traveler who is unable to clearly state what their medical problems are or what medications they take will realize the usefulness of this information. Finally, older travelers should be reminded that Medicare does not provide coverage in other countries and that additional health insurance coverage should be encouraged. A suggested “checklist” for patients contemplating travel is shown in Table 20–1.

Cruise ships are a very popular vacation mode for elders. Recent publicity aside, ship travel as a mode of transportation is not very risky short of gross navigational miscalculation. Events such as collisions, running aground, or pirate attacks are highly publicized but are actually relatively infrequent. The principal risks to ship travelers actually involve the hazards of shore travel (eg, vehicle accidents, pedestrian accidents, and falls) which account for the vast majority of the traumatic medical problems while “cruising.” Although shipboard epidemics attributable to viral gastroenteritis caused by norovirus or viral upper respiratory infections are relatively uncommon occurrences, their appearance on a ship will be amplified by the contained environment. Although many viral illnesses are highly contagious when spread by ship’s staff, such as food handlers, or by other travelers who are infected, good epidemiologic surveillance is effective in limiting shipboard epidemics. Ships registered in countries with rigorous public health standards enforced by government agencies (eg, the United States and the United Kingdom) may be less likely than ships of some other countries to present infectious disease risks to travelers. Data about individual cruise lines and individual ships are readily available from the Centers for Disease Control and Management in the form of the “Green Sheet” previously mentioned. Most larger cruise ships have a medical department aboard that can provide initial care for minor illness or injury and can help in arranging medical evacuation in more serious situations.

“If there is a physician on board, could you please identify yourself to a flight attendant?” Some estimates suggest that 60% to 70% of physicians have been involved in some sort of in-flight medical emergency. While in-flight medical emergencies are haphazardly recorded and there is little follow up among the airlines, it is estimated that in-flight emergencies occur between 0.4 and 3.4 per 100,000 passenger trips. One study of in-flight emergencies showed approximately 3% were sudden death and some 13% were “significant” cardiovascular problems, including myocardial infarctions and cerebrovascular accidents. Given the number of worldwide flights daily, estimates are that there are approximately 30 in-flight emergencies each day.

The nature and estimated frequencies of in-flight emergencies are shown in Table 20–2. It is clear that older adults will be at greater risk of in-flight emergencies from some, but not all, of these causes. They will have a greater probability of having coronary artery disease (either known or unknown), chronic obstructive pulmonary disease, syncope because of autonomic dysregulation, and perhaps more confusion from various causes such as underlying cognitive impairment or adverse medication side effects. Because the health professional facing an in-flight emergency involving an older adult does not have the diagnostic support to make more than a “best guess” about the cause of the distress, consideration must be given to the illness frequencies shown in Table 20–2 that might account for the observed problem.

The health professional can benefit from knowledge about what resources are available in the event of an emergency and a recounting of those resources is in order.

1. Flight attendants are experienced, trained in emergency procedures, and have some training in emergency first aid. Many have “been there and done that” during in-flight medical emergencies, so consult them early and often!

2. Most U.S. carriers have an experienced physician trained in emergency medicine and aerospace medicine available for consultation by air-to-ground communication. As a general rule, any emergency where diverting the aircraft for an unscheduled landing is being considered will require approval from this “on-call flight surgeon” as well as the Captain of the aircraft.

3. All U.S. aircraft having one or more flight attendants will have an automatic external defibrillator (AED) on board. The flight attendants will be trained in its operation. An AED can indicate the cardiac rhythm and will not administer a shock unless the rhythm is one that may respond to the shock.

4. Most major carriers and all U.S. airlines except “commuter airlines” must have an “Enhanced On-Board Emergency Medical Kit.” This kit contains diagnostic equipment (blood pressure cuff, stethoscope, etc), oropharyngeal airways, intravenous infusion equipment, oral medications, injectables, inhalers and resuscitation equipment including an Ambu bag, laryngoscope and airways. Table 20–3 is a more complete enumeration of the contents.

5. Larger jet aircraft carry medical oxygen in “walk around” tanks and the number of tanks varies with the size of the aircraft. Each tank supplies approximately thirty minutes of oxygen so extended hours of oxygen support will not be possible. “Commuter airlines” aircraft are not required to carry medical oxygen and will usually not have the “Enhanced Emergency Medical Kit.” Commuter aircraft will, however, have an AED onboard if the aircraft has at least 1 flight attendant.

Some older adults have such severe medical problems that flying is not advised. The most common contraindication to air travel is pulmonary insufficiency with chronic obstructive pulmonary disease (COPD) being the most common diagnosis. A PaO₂ (partial pressure of arterial oxygen) of less than 70 mm Hg at rest is usually a contraindication to air travel. In essence, any medical condition requiring supplemental oxygen at rest should be carefully evaluated to see if the stress of flying at a cabin pressure altitude of 6000 to 8000 feet can be tolerated. Supplemental oxygen can be arranged on-board and the duration of the oxygen administration is not constrained by the limited amount of emergency medical oxygen on board. Prior arrangements with the airline must be made and consultation with the medical department of the airline must be completed so the appropriate flow rate of the oxygen at altitude can be determined in advance. As a general rule, passengers may not take their personal oxygen tanks on board the aircraft and only certain types of concentrators are approved by the Federal Aviation Administration for use on board. Other medical problems that are contraindications to flying include unstable coronary disease or a recent myocardial infarction (usually said to be 3 weeks prior), recent surgery (2–3 weeks for ear, nose, and throat [ENT], ocular, or gastrointestinal surgery, and several more weeks for orthopedic surgery where DVT risk is increased), significant neurologic disability or recent stroke and behavioral issues caused by cognitive impairment or psychiatric problems.

The question of liability in responding to an on-board medical emergency was somewhat clarified in the United States in 1998 by the passage of the Aviation Medical Assistance Act (Public Law 105-170) which provides some “good samaritan” protection to health professionals rendering aid in a medical emergency in flight. To be covered by this law, the health professional must render care in good faith, be “medically qualified,” be a volunteer and must not accept monetary payment for services rendered. The medical care rendered “must be similar to the care that others with similar training would provide under such circumstances.” The United States, Canada, and the United Kingdom do not require health professionals to volunteer to provide care in an emergency, but many European countries and Australia do. The flag of the airline determines whether health professionals are or are not “required” to provide care. It is clear that enforcement of the “must volunteer” provision is problematic. Some uncertainty about legal jurisdiction in the case of international flights or even domestic flights over various states remains unsettled by case law as few lawsuits against health professionals providing care in medical emergencies in flight are on record. In-flight emergencies are best handled if the provider is aware of the treatment resources available on board the aircraft, is prepared to render care in the face of considerable uncertainty because of the lack of diagnostic information, provides care only “within the scope of a person with similar training,” and understands that, in the final analysis, clinical decisions made at 35,000 feet are often “your best guess.”

Some understanding of the risks of travel by older adults, resources for planning in advance of travel and what resources are available to health professionals in the event of being called to help in a medical emergency will better prepare both the elder traveler and the responding health professional when that “dreaded call” comes over the public address system in the midst of a journey.