The Golden Years: Providing pretravel care for older adults

As of July 2021, 18.5% of Canada’s population was 65 years of age or older.1 As this demographic grows, pharmacists are likely to encounter more older adults planning to travel. This column reviews some key considerations for pharmacists when providing care to older travellers. Travel health risks Morbidity is higher among older travellers compared to younger travellers across a number of causes, including lower respiratory tract infections, highaltitude pulmonary edema, phlebitis and pulmonary embolism, arthropod bites, severe malaria, gastroesophageal reflux disease, urinary tract infections and heart disease.2,3 Older adults may take longer to adjust to changes in altitude or humidity, and be more prone to motion sickness, jet lag, insomnia and constipation.4 Readers are referred to previous Travel Health columns for advice on the prevention of malaria,5 the selection and use of insect repellents,6 and the prevention of thrombosis.7 Additional measures to consider in older adults to reduce the risk of travel-related illness include reinforcing the importance of hand hygiene and influenza and pneumococcal vaccination, as well as providing advice on progressive acclimatization to altitude and considering the use of acetazolamide for the prevention of altitude illness.3 Depending on a patient’s medical history, destination and itinerary, clinicians may also consider providing standby antibiotics for the treatment of respiratory or urinary tract infections while travelling,3 with counselling on how to recognize signs and symptoms requiring treatment, and when to seek medical care. Chronic disease management Travel can introduce significant disruption to daily routines. Changes in dietary habits, sleep patterns and time zones can impact both chronic disease control and medication adherence. Try to optimize control of any chronic diseases prior to travel. Encourage pretravel assessments at least four to six weeks prior to planned travel, when possible. Simplify medication regimens to reduce the number of daily medication administration times. Remind travellers to store all medications in carry-on baggage, in the original containers. Use of blister packs when travelling may help with both packing and adherence. Those travelling with opioids or syringes should check with the embassy of their destination country(ies) about border crossing requirements; copies of the original prescription or a letter from a healthcare provider on letterhead may be required. For medications that require regular bloodwork, pre-arrange these services abroad as much as possible, to reduce the risk of loss of disease control. When available and appropriate, encourage travellers to increase their use of pointof-care and self-monitoring devices while abroad. Point-of-care INR test devices may be considered in place of lab testing for some patients on warfarin, but due to cost, this option is usually only explored by repeat or long-term travellers, such as “snowbirds.” Changes in dietary patterns may warrant increased blood glucose monitoring in those with diabetes, especially if using insulin. With this anticipated increase in use, be sure travellers pack enough glucose test strips for the duration of travel. Also, pack medications used on an as-needed basis for symptom management (e.g., salbutamol in patients with asthma or nitroglycerin spray), even if not used regularly prior to travel, as travel may trigger an exacerbation. Travel insurance Encourage all travellers to hold sufficient travel insurance, particularly older adults with comorbidities. Government-funded health insurance plans generally do not cover (or minimally cover) out-ofcountry expenses. Ensure coverage is provided for pre-existing conditions; these may be excluded by some plans. Travel health insurance should also cover repatriation costs, if the required care is not readily available at the destination. Travellers should always carry their insurance information with them, and leave a copy with a family member or friend at home. Immunosenescence Immunosenescence—an age-related decline in immune function—places older adults at increased risk of infectious diseases and their complications, and reduced effectiveness of vaccination. Remind older travellers that their age puts them at increased risk for vaccine-preventable and other diseases, making preventive measures especially important, including vaccination, use of insect repellent, adherence to malaria prophylaxis, and food and water precautions. Older adults are more likely to experience severe malaria compared with younger travellers and, while more likely to be adherent to malaria chemoprophylaxis, they may be less adherent to insect bite precautions.8 A lower incidence of traveller’s diarrhea has been reported in older compared to younger travellers, largely due to greater avoidance of street food and open drinks;9 however, older adults may be more prone to dehydration or other complications if traveller’s diarrhea occurs. Drug interactions, doses Increasing age is associated with an increased prevalence of chronic diseases and, subsequently, medication use.10 Drug interactions require particular attention among older travellers, as detailed in a previous Travel Health column.11 Changes in pharmacokinetics and pharmacodynamics associated with aging may warrant special considerations in drug selection and dosage. For example, commonlyused medications for prevention and treatment of motion sickness (e.g., dimenhydrinate, scopolamine) or jet lag (e.g., melatonin) may cause more sedation or anticholinergic side effects in an older traveller, requiring cautious use at the lowest effective dose. Yellow fever vaccination It is a common misconception that yellow fever vaccination is contraindicated in older adults. This relates to the agerelated increased risk of yellow fever vaccine-associated neurologic disease and viscerotropic disease; however, these risks are low.12,13 Yellow fever vaccination may be pursued in older travellers when there is a considerable risk of yellow fever transmission, after an assessment of the traveller’s itinerary and current disease prevalence and transmission in the country(ies) to be visited.14 Consider a waiver for those at low risk of exposure who are contemplating vaccination only because it is required by a country for entry. If a waiver is provided, remind travellers about the importance and proper use of insect repellent to minimize their risk of exposure to yellow fever and other vectorborne diseases. Summary Pretravel consultations for older adults need to be personalized, considering their destination, itinerary and medical history. Optimize the control of chronic disease(s) prior to travel, if possible, and reinforce the importance of adherence to medications. Medically complex older travellers should consider a fitness to travel assessment prior to travel, and those planning unusually strenuous activity should consider a preconditioning program in the weeks leading up to travel. Table 1 summarizes additional tips for older travellers. Sherilyn Houle, BSP, PhD, is an assistant professor, School of Pharmacy, University of Waterloo, ON, and a pharmacist at the International Travel & Immunizations Clinic, Centre for Family Medicine in Kitchener, ON. She has her Certificate in Travel Health from the International Society of Travel Medicine. References Statistics Canada. Population and demography statistics. https://www.statcan.gc.ca/en/subjectsstart/population_and_demography (accessed January 30, 2022). Lawson CJ, Dykewicz CA, Molinari NAM, et al. Deaths in international travelers arriving in the United States, July 1, 2005 to June 30, 2008. J Trav Med 2012;19(2):96-103. Gautret P, Gaudart J, Leder K, et al. Travelassociated illness in older adults (>60 y). J Trav Med 2012;19(3):169-77. Suh KN. The older traveller. In: Keystone JS, Freedman DO, Kozarsky PE, et al. Travel medicine. 3rd edition. Elsevier; 2013. p. 241-48. Houle S. The ABCD approach to malaria prevention. Pharm Pract Business 2020;7(1):16-8. Houle S. The DEETails on insect repellent alternatives. Pharm Pract Business 2019;6(5):15-6. Houle S. Travellers’ thrombosis – not just an ‘economy class syndrome.’ Pharm Pract Business 2021;8(1):27-8. Del Prete V, Mateo-Urdiales A, Bueno-Cavanillas A, et al. Malaria prevention in the older traveller: a systematic review. J Trav Med 2019;26(7):taz067. Alon D, Shitrit P, Chowers M. Risk behaviors and spectrum of diseases among elderly travellers: a comparison of younger and older adults. J Trav Med 2010;17(4):250-5. Reason B, Terner M, McKeag AM, et al. The impact of polypharmacy on the health of Canadian seniors. Fam Pract 2012;29(4):427-32. Houle S. Common drug interactions in travel medicine. Pharm Pract Business 2022:9(2):26-7. Lindsey NP, Rabe IB, Miller ER, et al. Adverse event reports following yellow fever vaccination, 2007–13. J Travel Med 2016; 23:taw045. Gershman MD, Staples JE. Yellow fever. In: CDC Yellow Book 2020. https://wwwnc.cdc.gov/travel/ yellowbook/2020/travel-related-infectious-diseases/ yellow-fever (accessed February 1, 2022). Committee to Advise on Tropical Medicine and Travel. Statement for travellers and yellow fever. https://www.canada.ca/en/public-health/services/ reports-publications/canada-communicable-diseasereport-ccdr/monthly-issue/2013-39/statementtravellers-yellow-fever.html (accessed February 1, 2022).