1. Peter A. Leggat, MD, PhD, DrPH, FAFPHM, FACTM, FFTM Associate Professor School of Public Health and Tropical Medicine James Cook University Travel health for special groups: Older travelers

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

3. Objectives of the session To review the general approach to travel health advice To review the general approach to travel health advice To familiarize ourselves with some of the potential health concerns relevant to older travelers To familiarize ourselves with some of the potential health concerns relevant to older travelers

4. As quoted from The White House, Travel section. Available at: http://www.whitehouse.gov/government/handbook/travel.html (accessed 19 March 2005) http://www.whitehouse.gov/government/handbook/travel.html Travel, in the younger sort, is a part of education; in the elder, a part of experience Francis Bacon 1612

5. Introduction 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.

6. General Approach (after Ericsson, 2003) Risk assessment, determining the risks of the destination, mode of travel and the special conditions of the traveler Risk assessment, determining the risks of the destination, mode of travel and the special conditions of the traveler Vaccinate when possible and indicated; Vaccinate when possible and indicated; Provide the traveler with appropriate empirical self-treatment Provide the traveler with appropriate empirical self-treatment Consider chemoprophylaxis Consider chemoprophylaxis

7. General Approach (after Ericsson, 2003) Consider any concerns regarding underlying conditions and possible drug interactions Consider any concerns regarding underlying conditions and possible drug interactions Consult experts in travel medicine or specialty areas as necessary Consult experts in travel medicine or specialty areas as necessary Educate the traveler Educate the traveler Remind the traveler that these precautions are not 100% protective Remind the traveler that these precautions are not 100% protective

8. Some common problems Motion sickness Motion sickness Jet lag Jet lag Heatstroke and hypothermia Heatstroke and hypothermia Thromboembolic disease Thromboembolic disease Injuries and accidents Injuries and accidents Travelers’ diarrhea Travelers’ diarrhea Malaria Malaria Vaccine preventable disease Vaccine preventable disease Issues associated with disability, including exercise tolerance, visual or hearing impairment Issues associated with disability, including exercise tolerance, visual or hearing impairment

9. Motion sickness Common in any traveling group Common in any traveling group Cruise ship travel popular with older travelers Cruise ship travel popular with older travelers www.cdc.gov/travel has link to cruise ship sanitation inspections www.cdc.gov/travel has link to cruise ship sanitation inspections www.cdc.gov/travel

10. Motion sickness Nonpharmacological Nonpharmacological –e.g. distant horizon, close eyes Pharmacological Pharmacological –e.g. diphenydramine, hyoscine (c.i. glaucoma and prostatic hypertrophy)

11. Jet lag Older travelers may be more susceptible Older travelers may be more susceptible Nonpharmacological Nonpharmacological –well-rested, adaption of activities to destination time Pharmacological Pharmacological –e.g. benzodiazepines, melatonin may offer help for some travelers

12. Heatstroke and hypothermia Older travelers may be more susceptible to effects of extreme temperatures Older travelers may be more susceptible to effects of extreme temperatures Consider Consider –Gradual acclimatization –Adequate hydration –Appropriate clothing –Caution with pharmaceutical agents, which may impair thermoregulation, e.g. beta blockers, antihistamines, diuretics, and anticholinergic agents

13. Thromboembolic disease Increased risk of venous thromboembolism in those with known venous disorders and cardiac disease Increased risk of venous thromboembolism in those with known venous disorders and cardiac disease Dehydration and prolonged immobility may be problematic in these individuals Dehydration and prolonged immobility may be problematic in these individuals Non-pharmaceutical Non-pharmaceutical –e.g. in-flight exercise, compression stockings Pharmaceutical for high risk travelers Pharmaceutical for high risk travelers –e.g. subcutaneous heparin

14. Injuries and accidents Motor vehicle accidents are a major cause of morbidity and mortality in various age group Motor vehicle accidents are a major cause of morbidity and mortality in various age group Older travelers may be at increased risk due to slower reaction times, visual/auditory impairments, adverse effects of medications etc Older travelers may be at increased risk due to slower reaction times, visual/auditory impairments, adverse effects of medications etc

15. Travelers’ 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.

16. Malaria Incidence of severe illness and death increases with age Incidence of severe illness and death increases with age Nonpharmaceutical Nonpharmaceutical –e.g. DEET Pharmaceutical Pharmaceutical –e.g. chemoprophylaxis usually well tolerated –Caution with some drugs, e.g. mefloquine in cardiac and neuropsychiatric conditions

17. Vaccine preventable diseases Routine immunizations should be checked/boostered Routine immunizations should be checked/boostered 65 and over: pneumococcal vaccine and annual influenza immunization 65 and over: pneumococcal vaccine and annual influenza immunization Age alone not really contraindication to vaccination Age alone not really contraindication to vaccination Seroconversion rates may decrease with age Seroconversion rates may decrease with age

18. Vaccine preventable diseases Hepatitis A screening may be cost effective in older travelers due to higher seropositive rates Hepatitis A screening may be cost effective in older travelers due to higher seropositive rates Remember hepatitis A is generally a more severe disease in older travelers Remember hepatitis A is generally a more severe disease in older travelers Live vaccines (oral typhoid, oral polio, varicella, yellow fever) need to be used with caution in immunocompromised travelers Live vaccines (oral typhoid, oral polio, varicella, yellow fever) need to be used with caution in immunocompromised travelers

19. Illness and Disability Increasing incidence of medical problems with age Increasing incidence of medical problems with age Physically demanding trips needs to be balanced with exercise tolerance Physically demanding trips needs to be balanced with exercise tolerance Control of pre-existing disease important, as important cause of morbidity and mortality abroad Control of pre-existing disease important, as important cause of morbidity and mortality abroad Travel insurers may require medical risk assessment with older travelers and those with preexisting disease Travel insurers may require medical risk assessment with older travelers and those with preexisting disease

20. Want more information? Older travellers – –McIntosh IB. Health hazards and the elderly traveler. J Travel Med 1998; 5: 27-29

21. Textbooks Many textbooks have useful chapters dealing with issues related to older travelers Many textbooks have useful chapters dealing with issues related to older travelers –Manual of Travel Medicine and Health (Steffen et al., 2003) –Principles and Practice of Travel Medicine (Zuckerman, 2001) –Primer of Travel Medicine (Leggat et al., 2002)

22. Specific WWW sites Internet Guide to Travel Health by Connor, 2004 (Harworth Press) Specific WWW sites Internet Guide to Travel Health by Connor, 2004 (Harworth Press) Older travelers Older travelers –Elderly travelers (http://www.fitfortravel.scot.nhs.uk/gener al/elderly.html) http://www.fitfortravel.scot.nhs.uk/gener al/elderly.htmlhttp://www.fitfortravel.scot.nhs.uk/gener al/elderly.html –FirstGov for seniors-travel and leisure (http://www.firstgov.gov/topics/seniors.s html) http://www.firstgov.gov/topics/seniors.s htmlhttp://www.firstgov.gov/topics/seniors.s html –Infirm travelers (http://www.faa.gov/acr) (Karl Newman) http://www.faa.gov/acr

23. General WWW resources www.who.int/ith www.who.int/ith www.who.int/ith www.cdc.gov/travel www.cdc.gov/travel www.cdc.gov/travel www.istm.org www.istm.org www.istm.org

24. Last 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.