Travel and Wilderness Medicine for Older Adults

Educational Objectives

The goal of this program is to improve prevention of travel-related illnesses in older adults. After hearing and assimilating this program, the clinician will be better able to:

1. Administer fluoroquinolones appropriately in older adults planning to travel.
2. List contraindications for air travel in older adults.
3. Cite causes of deep vein thrombosis in older adults during long flights.

Summary

Physiologic changes with aging: include decreased maximal oxygen consumption (VO₂ max), decreased cardiac output, increased arrhythmias, decreased elasticity of the thorax, reduced muscle mass, diminished gas exchange area, and bone loss; physical performance declines gradually over time; the exception is ultra-endurance athletes who may peak later in life; alterations in vision, eg, macular degeneration, cataracts, may occur; hearing changes are evident in individuals using Bluetooth devices; balance issues may be caused by neuropathies, decreased sensory input, and slower brain adjustments

Falls: issues related to aging may increase the risk for falls, which can lead to traumatic brain injuries, orthopedic injuries, and a decline in overall health; exercise, balance training, and regular eye and hearing tests help in preventing falls and reducing the risk for injuries

Physical activity: evidence suggests a significant increase in inactivity with age, particularly in women; Rothenbacher et al (2006) showed individuals who exercised often had higher exercise ability with age than those who were sedentary; physical activity in later adulthood reduces the risk for myocardial infarction (MI); a meta-analysis by Cunningham et al (2020) showed physical activity in older adults reduces mortality by ≈28% and decreases cardiovascular mortality and cancer risk; exercising reduces fracture risk and disability and improves the quality of life; Defina et al (2013) showed the risk for dementia was lowest in people who were most active

Hyperthermia: older individuals are more prone to heat exhaustion or heat stroke; they are less able to regulate their body temperature because of changes in brain responses, reduced sweating, and increased insulation; additionally, certain medications, eg, diuretics and anticholinergics, may further exacerbate the risk for hyperthermia

Risk factors: include obesity, hypertension, diabetes mellitus, neuropathies, and autonomic issues; medications include antihistamines, β-blockers, diuretics, alcohol, lithium, thiazides, psychotropic drugs (eg, cocaine, methamphetamine), and tricyclic antidepressants; atropine is a strong anticholinergic; diphenhydramine (eg, Banophen, Benadryl, Nytol) and scopolamine also have anticholinergic properties; many medications, including prednisone, furosemide, and ranitidine, have subtle anticholinergic effects that can accumulate and contribute to heat-related issues; medications, eg, warfarin, acetazolamide, can impair heat loss and increase the risk for heat stroke, especially in older patients or those with chronic illnesses

Hypothermia: older adults shiver less; shivering is a crucial mechanism for generating heat; medications, eg, pethidine (eg, Demerol), can impair this ability, leading to increased hypothermia; decreased vasoconstriction leads to greater heat loss; paradoxical undressing, where people remove clothing despite being cold, is a common response in older individuals with hypothermia, which exacerbates the condition

Strategies for dealing with environmental stresses: it is important to acclimatize, pace oneself, hydrate, and adjust medications as needed; for cold environments, wear sufficient clothing and maintain awareness of peers; heat acclimatization involves expanding plasma volume, improving skin blood flow, lowering the sweating threshold, and increasing sweating; acclimatization leads to increased sweating with reduced salt loss

Altitude: older adults are at lower risk for acute mountain sickness, possibly because of a better hypoxic ventilatory response and smaller brain size; altitude sickness may be related to hypoxia and brain swelling and may be less common in older individuals because of brain shrinkage

Climbing Everest: older climbers have a lower success rate of reaching the summit (50% for individuals >40 yr of age) and a higher death rate (4% vs 9%); most deaths are attributed to underlying illnesses rather than trauma or altitude sickness; there is a significant decrease in success rates for climbers >60 yr of age, which could be because of impaired performance and increased caution; aging has some benefits for climbers, eg, decreased altitude sickness and motion sickness

Pre-travel preparation: key factors include conditioning, eye and ear examinations, carrying medical records electronically, having appropriate health insurance, and ensuring adequate documentation for prescription medications; travelers must carry extra supplies, eg, batteries for hearing aids or glasses, to avoid inconvenience in case of loss or damage; documentation of past surgeries is important if the hardware is present; bilateral hip or knee replacements can trigger airport metal detectors; carry medical alert bracelets for chronic illnesses

Medications: the average older adult takes 5 medications, many of which need to be continued and can affect performance; avoid abrupt discontinuation; do not stop aspirin if stents are present; statins have a theoretical risk for rebound; there are definite changes with selective serotonin reuptake inhibitors; β-blockers can have rebound effects; cancer medication should not be stopped; β-blockers reduce heart rate and cardiac output; diuretics require careful management of fluid intake; fluoroquinolones increase the risk for tendon rupture, especially in older patients and those taking steroids; they are not recommended to be used as a prophylactic agent for traveler’s diarrhea; discontinue fluoroquinolones if the patient develops tendonitis; even younger patients are at risk

Anticoagulation: consider why the patient is on anticoagulation, whether they need to stay on anticoagulation, options for therapy, drug interactions, and how anticoagulation will be monitored during travel; the most common indication in older patients is atrial fibrillation; mechanical heart valves are rarer but require warfarin; venous thrombosis is another indication; direct oral anticoagulants (DOACs) are a good option for travel, but can be expensive; DOACs have infrequent drug interactions with some HIV medications and azoles but otherwise have few interactions; warfarin has many interactions; international normalized ratio (INR) monitors are available for rent, and INR can be tested in many countries

Medications: ensure an adequate supply for the trip; pack essential medication in carry-on luggage; for controlled substances and injectables, some countries require a prescription and/or a physician’s letter; ensure up-to-date vaccinations; the Centers for Disease Control and Prevention Yellow Book is available for travel advice for other countries; yellow fever vaccination is not recommended unless there is a genuine risk or a country requires it; the clinician may choose to begin new medications, novel hypnotic agents, and malaria prophylaxis at home to avoid potential adverse effects in unfamiliar environments

Trauma: is the second most common cause of travel-related death in older patients, particularly motor vehicle accidents; it is recommended to avoid risky behaviors and use safe forms of transportation

Cardiac disease: is the most common cause of air travel death; the overall risk for a fatal MI is significantly lower in individuals who are physically active; sudden death is rare, with an estimated rate of 1 event per 1,600,000 hr of skiing; sudden death tends to happen on the first day of activity, likely because of the sudden increase in activity, particularly at high altitude; risk factors include a history of MI, coronary artery disease, and hypertension

Travel considerations: asymptomatic patients — the clinician should understand the patient's planned activity level; exercise testing is rarely needed; consider conditioning well ahead of time before traveling; take a good travel and exercise history for those planning high-performance activities, especially at altitude; pre-existing cardiac disease is not necessarily a problem at altitude because of compensation, especially if activity is consistent with baseline activity

Contraindications for air travel: include cardiac surgery in the previous 3 wk, poorly compensated heart failure, and certain types of arrhythmias

Cardiac disease: after an MI, rehabilitation should match the planned travel; patients with implantable cardioverter defibrillators and pacemakers need paperwork; a copy of baseline electrocardiography is key; many individuals with cardiac disease can safely travel with appropriate management

Neuropathies: increase the risk for frostbite, blisters, and infections; patients must be educated regarding foot care, especially those engaging in hiking; counsel the patient to wear well-fitting shoes and boots and to seek early aggressive care for wounds and blisters

Prosthetic joints: physical therapy is important for rehabilitation and maintenance of activity levels; there is increasing lenience on activity

Thrombosis: travel is a consistent risk factor for deep venous thrombosis (DVT); traveling for >4 hr on an airplane carries a risk similar to mild surgery; pulmonary emboli are rare; minor thrombosis is common; risk increases considerably at >12 hr; most individuals who develop DVT have pre-existing risk factors; venous stasis is the primary cause, not hypoxia, with dehydration playing a minor role; aspirin does not help; simple measures, eg, avoiding tight clothing, staying hydrated, and performing calf exercises can help mitigate the risk; for high-risk individuals, knee-high compression stockings with 15 to 30 mm Hg at the ankle are recommended; one dose of rivaroxaban before the flight may be appropriate for people with previous DVT

Readings

Albini A, La Vecchia C, Magnoni F, et al. Physical activity and exercise health benefits: cancer prevention, interception, and survival. Eur J Cancer Prev. Published online June 26, 2024. doi:10.1097/CEJ.0000000000000898. View Article; Laskowski-Jones L. Wilderness medicine. Nursing. 2024;54(7):6-6. doi:10.1097/NSG.0000000000000037. View Article; Luks AM, Hackett PH. Medical conditions and high-altitude travel. New Engl J Med. 2022;386(4):364-373. doi:10.1056/NEJMra2104829. View Article; Pryor RR, Bennett BL, O'Connor FG, et al. Medical evaluation for exposure extremes. Clin J Sport Med. 2015;25(5):437-442. doi:10.1097/JSM.0000000000000248. View Article; Rosenbaum A, Stringer J. Travel medicine. Obstet Gynecol. 2020;136(5):1074-1074. doi:10.1097/AOG.0000000000004136. View Article; Salem MA, Mahrous OA, Gabr I. Role of family physician in healthcare for persons traveling abroad. Menoufia Med J. 2015;28(2):587-590. doi:10.4103/1110-2098.163923. View Article; Sorensen C, Hess J. Treatment and prevention of heat-related illness. N Engl J Med. 2022;387(15):1404-1413. doi:10.1056/NEJMcp2210623. View Article; Turner L, Hamilton E. Travel medicine updates for the NP. Nurse Practitioner. 2024;49(7):32-37. doi:10.1097/01.NPR.0000000000000205. View Article.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. DeLoughery was recorded at When Things Go Wrong in the Outdoors, held August 15-16, 2024, in Government Camp, OR, and presented by Oregon Health and Science University. For information on upcoming CME activities from this presenter, please visit ohsu.edu/school-of-medicine/cpd. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

FP724401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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