Keeping older patients healthy and safe as they travel

There is no evidence to recommend the use of aspirin to prevent VTE.^12,13 But you may consider prescribing a single 40-mg dose of enoxaparin for a patient who has multiple risk factors and will be airborne for >6 hours.¹³

Promote safety and comfort on the ground

It is crucial to remind all travelers about the risks associated with traveling in motor vehicles in other countries. Remind patients to wear seat belts whenever they’re available; exercise caution regarding public transportation, which may be overcrowded and have an increased risk of pickpockets and robbery; and avoid riding on motorcycles and scooters. If they do opt to ride on a scooter, tell them that it’s imperative that they wear a helmet.

Minimize the effects of jet lag
Travelers of any age may experience jet lag, which occurs when the individual’s circadian clock cannot keep pace with travel across time zones.¹⁴ Notably, however, older people appear to suffer less than their younger counterparts.³ Patients traveling great distances are not likely to avoid jet lag completely, of course. Recommend the following strategies:

Start adjusting your schedule in the week before you depart, gradually shifting 2 hours toward congruence with the time zone at your destination.¹⁴

Help reset your circadian rhythm through exposure to bright light, in the morning after eastward travel and in the evening after westward travel.¹⁴

Take it easy at first. An itinerary that accounts for initial fatigue is an important nonpharmacologic management strategy.¹⁴

Avoid sedating medications, including antihistamines, tranquilizers, anti-motion sickness agents, and benzodiazepines, as these can increase falls and confusion in older adults and make jet lag worse.³

Take melatonin. A dose of 0.5 to 5 mg, taken at bedtime, may promote sleep and decrease jet lag symptoms in travelers crossing multiple time zones.¹⁴

Prepare patients to cope with heat …
Unusually hot, humid weather increases morbidity and mortality in the elderly,^3,15 and older patients traveling to such climates will need to take extra precautions. Strenuous exercise in the heat should be avoided, because both thirst and the capacity to conserve salt and water decrease with age.¹⁶ Acclimatization is helped by rest, air-conditioning, loose cotton clothing, brimmed hats, and cool baths or showers.³ Diuretics may have to be adjusted for fluids lost by increased perspiration, and a discussion about a dose reduction should be included in the pretravel consult for patients who take diuretics and will be traveling to a hot, humid climate.

… and increases in altitude
For older adults, exposure to a moderate altitude (<2500 meters) is initially associated with hypoxemia and a reduced exercise capacity, until acclimatization occurs by Day 5.^17,18 Although older adults generally acclimatize well, advise them to limit their activities for the first few days at a higher altitude. This is especially important for patients with coronary artery disease (CAD).

To further ease the effects of a higher altitude, advise patients to drink plenty of fluids, but little or no alcohol.¹⁹ Review the medications of an older patient who will be spending time at very high altitude. Rarely, antihypertensive medication may need to be adjusted. The body compensates for lower oxygen with a faster heart rate, and some antihypertensives may interfere with this compensatory mechanism.³

Precautions (and prophylaxis) may prevent travelers’ diarrhea

Diarrhea—among the most common travel-related conditions²⁰—affects an estimated 30% to 70% of international travelers.² The incidence is highest among visitors to developing countries. Most (80%-90%) of travelers’ diarrhea is due to bacterial infection,²¹ 10% of cases are caused by parasites, and 5% to 8% by viral infection.^2,22

Although increasing age lowers the risk of travelers’ diarrhea,¹ older patients traveling to developing areas should be cautioned to only eat food that is served hot or fruit they can peel themselves; drink only bottled water and sealed liquids; and avoid salad, ice, and food from street vendors.¹ Studies have shown, however, that tourists often get diarrhea despite these safety measures.²

Treatment and prophylaxis. Prophylactic antibiotics can prevent travelers’ diarrhea. But the increased sun sensitivity, drug-drug interactions, and gastrointestinal (GI) adverse effects associated with antibiotics limit their usefulness. Prophylaxis is indicated, however, for older adults for whom the complications of dehydration would likely be so severe that the benefits of using antibiotics to prevent diarrhea clearly outweigh the risks.²³

Fluoroquinolones are a first-line treatment for travelers’ diarrhea. But increasing microbial resistance to this class of drugs, especially among Campylobacter isolates,²⁴ may limit their usefulness in some destinations.²⁵ Azithromycin is recommended in such cases, and has been shown to be equally effective.^26,27 Single-dose therapy is well established with fluoroquinolones, but the best regimen for azithromycin (1 vs 3 days) is still under evaluation.^28,29 Along with instructions on when to take an antibiotic, travelers should be given prescriptions for treatment of travelers’ diarrhea before the start of their trip. Suggest that patients purchase oral rehydration packets to take on their trip, and stress the importance of using them and staying hydrated if diarrhea develops.