Peter A. LeggatPeter A. Leggat, , MD, PhD, DrPH, FAFPHM, MD, PhD, DrPH, FAFPHM, FACTM, FFTMFACTM, FFTM

Associate ProfessorAssociate Professor

School of Public Health and Tropical MedicineSchool of Public Health and Tropical Medicine

James Cook UniversityJames Cook University

Travel health for special Travel health for special groups:groups:

Older travelersOlder travelers

About the authorAbout the author

• Dr Peter Leggat has co-ordinated the Dr Peter Leggat has co-ordinated the Australian postgraduate course in travel Australian postgraduate course in travel medicine since 1993. He has also been medicine since 1993. He has also been on the faculty of the South African travel on the faculty of the South African travel medicine course, conducted since 2000, medicine course, conducted since 2000, and the Worldwise New Zealand Travel and the Worldwise New Zealand Travel Health update programs since 1998. Dr Health update programs since 1998. Dr Leggat has assisted in the development Leggat has assisted in the development of travel medicine programs in several of travel medicine programs in several countries and also the Certificate of countries and also the Certificate of Knowledge examination for the Knowledge examination for the International Society of Travel Medicine.International Society of Travel Medicine.

Objectives of the sessionObjectives of the session

• To review the general approach To review the general approach to travel health adviceto travel health advice

• To familiarize ourselves with To familiarize ourselves with some of the potential health some of the potential health concerns relevant to older concerns relevant to older travelers travelers

As quoted from The White House, Travel section. Available at: http://www.whitehouse.gov/government/handbook/travel.html (accessed 19 March 2005)

Travel, in the younger sort, is a part of education;

in the elder, a part of experience

Francis Bacon 1612

IntroductionIntroduction

• Average life expectancy is increasing in most developed countries.

• Retired older persons often want to travel.

• Up to 10% of travelers in tropical areas are older persons.

• In addition to other organs, the immune system function also becomes impaired.

General Approach General Approach (after Ericsson, 2003)(after Ericsson, 2003)

• Risk assessment, Risk assessment, determining the risks determining the risks of the destination, mode of travel and of the destination, mode of travel and the special conditions of the travelerthe special conditions of the traveler

• Vaccinate when possible and indicated; Vaccinate when possible and indicated;

• Provide the traveler with appropriate Provide the traveler with appropriate empirical self-treatmentempirical self-treatment

• Consider chemoprophylaxisConsider chemoprophylaxis

General Approach General Approach (after Ericsson, 2003)(after Ericsson, 2003)

• Consider any concerns regarding Consider any concerns regarding underlying conditions and possible underlying conditions and possible drug interactionsdrug interactions

• Consult experts in travel medicine or Consult experts in travel medicine or specialty areas as necessaryspecialty areas as necessary

• Educate the traveler Educate the traveler • Remind the traveler that these Remind the traveler that these

precautions are not 100% protectiveprecautions are not 100% protective

Some common problemsSome common problems

• Motion sicknessMotion sickness

• Jet lagJet lag

• Heatstroke and Heatstroke and hypothermiahypothermia

• Thromboembolic Thromboembolic diseasedisease

• Injuries and Injuries and accidentsaccidents

• Travelers’ diarrheaTravelers’ diarrhea

• MalariaMalaria

• Vaccine Vaccine preventable preventable diseasedisease

• Issues associated Issues associated with disability, with disability, including exercise including exercise tolerance, visual or tolerance, visual or hearing hearing impairmentimpairment

Motion sicknessMotion sickness

• Common in any traveling groupCommon in any traveling group

• Cruise ship travel popular with Cruise ship travel popular with older travelersolder travelers

• www.cdc.gov/travelwww.cdc.gov/travel has link to cruise has link to cruise ship sanitation inspectionsship sanitation inspections

Motion sicknessMotion sickness

• NonpharmacologicalNonpharmacological– e.g. distant horizon, close eyese.g. distant horizon, close eyes

• PharmacologicalPharmacological– e.g. diphenydramine, hyoscine (c.i. e.g. diphenydramine, hyoscine (c.i.

glaucoma and prostatic glaucoma and prostatic hypertrophy)hypertrophy)

Jet lagJet lag

• Older travelers may be more Older travelers may be more susceptiblesusceptible

• NonpharmacologicalNonpharmacological– well-rested, adaption of activities to well-rested, adaption of activities to

destination timedestination time

• PharmacologicalPharmacological– e.g. benzodiazepines, melatonin e.g. benzodiazepines, melatonin

may offer help for some travelersmay offer help for some travelers

Heatstroke and hypothermiaHeatstroke and hypothermia• Older travelers may be more susceptible Older travelers may be more susceptible

to effects of extreme temperaturesto effects of extreme temperatures

• ConsiderConsider– Gradual acclimatizationGradual acclimatization– Adequate hydrationAdequate hydration– Appropriate clothingAppropriate clothing– Caution with pharmaceutical agents, which Caution with pharmaceutical agents, which

may impair thermoregulation, e.g. beta may impair thermoregulation, e.g. beta blockers, antihistamines, diuretics, and blockers, antihistamines, diuretics, and anticholinergic agentsanticholinergic agents

Thromboembolic diseaseThromboembolic disease

• Increased risk of venous Increased risk of venous thromboembolism in those with known thromboembolism in those with known venous disorders and cardiac diseasevenous disorders and cardiac disease

• Dehydration and prolonged immobility Dehydration and prolonged immobility may be problematic in these individualsmay be problematic in these individuals

• Non-pharmaceuticalNon-pharmaceutical– e.g. in-flight exercise, compression e.g. in-flight exercise, compression

stockingsstockings• Pharmaceutical for high risk travelersPharmaceutical for high risk travelers

– e.g. subcutaneous heparine.g. subcutaneous heparin

Injuries and accidentsInjuries and accidents

• Motor vehicle accidents are a Motor vehicle accidents are a major cause of morbidity and major cause of morbidity and mortality in various age groupmortality in various age group

• Older travelers may be at Older travelers may be at increased risk due to slower increased risk due to slower reaction times, visual/auditory reaction times, visual/auditory impairments, adverse effects of impairments, adverse effects of medications etcmedications etc

Travelers’ diarrheaTravelers’ diarrhea

• Traveler’s diarrhea is sometimes more severe with older persons, increasing the risk of dehydration through loss of fluid and electrolytes.

• Prompt therapy is necessary. • It is important to consider possible

drug interactions as older persons often use multiple medications for chronic illnesses.

MalariaMalaria

• Incidence of severe illness and Incidence of severe illness and death increases with agedeath increases with age

• NonpharmaceuticalNonpharmaceutical– e.g. DEETe.g. DEET

• PharmaceuticalPharmaceutical– e.g. chemoprophylaxis usually well e.g. chemoprophylaxis usually well

toleratedtolerated– Caution with some drugs, e.g. Caution with some drugs, e.g.

mefloquine in cardiac and mefloquine in cardiac and neuropsychiatric conditionsneuropsychiatric conditions

Vaccine preventable Vaccine preventable diseasesdiseases

• Routine immunizations should be Routine immunizations should be checked/boosteredchecked/boostered

• 65 and over: pneumococcal vaccine 65 and over: pneumococcal vaccine and annual influenza immunizationand annual influenza immunization

• Age alone not really Age alone not really contraindication to vaccinationcontraindication to vaccination

• Seroconversion rates may decrease Seroconversion rates may decrease with agewith age

Vaccine preventable Vaccine preventable diseasesdiseases

• Hepatitis A screening may be cost Hepatitis A screening may be cost effective in older travelers due to effective in older travelers due to higher seropositive rateshigher seropositive rates

• Remember hepatitis A is generally a Remember hepatitis A is generally a more severe disease in older travelersmore severe disease in older travelers

• Live vaccines (oral typhoid, oral polio, Live vaccines (oral typhoid, oral polio, varicella, yellow fever) need to be varicella, yellow fever) need to be used with caution in used with caution in immunocompromised travelersimmunocompromised travelers

Illness and DisabilityIllness and Disability

• Increasing incidence of medical Increasing incidence of medical problems with ageproblems with age

• Physically demanding trips needs to be Physically demanding trips needs to be balanced with exercise tolerancebalanced with exercise tolerance

• Control of pre-existing disease Control of pre-existing disease important, as important cause of important, as important cause of morbidity and mortality abroadmorbidity and mortality abroad

• Travel insurers may require medical Travel insurers may require medical risk assessment with older travelers risk assessment with older travelers and those with preexisting diseaseand those with preexisting disease

Want more information?Want more information?

•Older travellers– McIntosh IB. Health

hazards and the elderly traveler. J Travel Med 1998; 5: 27-29

TextbooksTextbooks

• Many textbooks have useful Many textbooks have useful chapters dealing with issues chapters dealing with issues related to older travelersrelated to older travelers– Manual of Travel Medicine and Manual of Travel Medicine and

Health (Steffen et al., 2003)Health (Steffen et al., 2003)– Principles and Practice of Travel Principles and Practice of Travel

Medicine (Zuckerman, 2001)Medicine (Zuckerman, 2001)– Primer of Travel Medicine (Leggat Primer of Travel Medicine (Leggat

et al., 2002)et al., 2002)

Specific WWW sites Specific WWW sites Internet Guide to Travel Health by Internet Guide to Travel Health by Connor, 2004 (Harworth Press)Connor, 2004 (Harworth Press)

• Older travelersOlder travelers– Elderly travelers (Elderly travelers (

http://www.fitfortravel.scot.nhs.uk/general/eldhttp://www.fitfortravel.scot.nhs.uk/general/elderly.htmlerly.html))

– FirstGov for seniors-travel and leisure (FirstGov for seniors-travel and leisure (http://www.firstgov.gov/topics/seniors.shtmlhttp://www.firstgov.gov/topics/seniors.shtml))

– Infirm travelers (Infirm travelers (http://www.faa.gov/acrhttp://www.faa.gov/acr) ) (Karl Newman)(Karl Newman)

General WWW resourcesGeneral WWW resources

• www.who.int/ithwww.who.int/ith

• www.cdc.gov/travelwww.cdc.gov/travel

• www.istm.orgwww.istm.org

Last wordLast word• Fortunately, most older persons that are

traveling are in good health.• None-the-less, aging is accompanied by a global

immune deficit, which increases the incidence of cancers (55% of cancers occur after 65 years), auto-immune diseases, and infectious morbidity and mortality.

• It is important that older travelers must be encouraged to present for a pre-travel health consultation and obtain appropriate travel insurance.