First published June 2007, updated February 2022

Key points:

  • As the proportion of older people in the population increases, the number of older travellers will increase.
  • The function of all bodily systems diminishes with increasing age.
  • Pre-existing medical problems may come to light or be exacerbated during travel.
  • A pre-travel health and medication check is of prime importance.

Between 1971 and 2005, the population of the UK rose from 55.9 million to 60.2 million, and the proportion aged 65 or over grew from 13 per cent to 16 per cent1. This demographic trend means there will be a steadily higher proportion of elderly people who are not only living longer but who also have better health and financial status in their retirement. As a result of this, many elderly people wish to travel. For example, it has been estimated that 60 per cent of UK cruise passengers are over the age of 60 and one-third of those over the age of 65 travelled abroad over a period of one year. In 2001, there were over four million visits abroad by UK residents aged over 652. However, many elderly travellers do not take adequate account of the health problems they may face or the healthcare facilities likely to be available to them when travelling3. Also, many do not receive adequate healthcare information when booking their trip4. While many elderly travellers will remain healthy, the group as a whole is at increased risk of health problems. There is a decline in the function of organ systems with increasing age5 — including respiratory6, cardiovascular7, renal8 and cerebral function9, and immune responses10.

Many elderly people are functioning on the brink of normality in a familiar setting. The physical and mental stresses of travel may tip the balance into abnormal function of any of these systems, even in the absence of any pre-existing symptoms of disease. Pre-existing asymptomatic conditions may become symptomatic during travel and already symptomatic conditions may be exacerbated. Medication taken for pre-existing conditions may affect travel by producing adverse drug reactions.

Cardiovascular problems

Cardiovascular conditions are the principal cause of death in older travellers3 . Travel may lead to increased levels of exertion, particularly in those who are usually sedentary. Carrying baggage, walking long distances in airport terminals and taking sightseeing tours on foot may exacerbate pre-existing ischaemic heart disease or cause it to produce symptoms such as breathlessness and angina for the first time. Many package tours to destinations such as South America or parts of Asia may take travellers to high altitude. There is no clear link between high altitude and exacerbation of ischaemic heart disease per se, but the increased strenuousness of exertion at high altitude may precipitate the onset of symptoms. Travel-related deep vein thrombosis (DVT) has received much publicity in recent years. It is not specific to air travel and may occur on a long journey by any form of transport11, particularly on journeys lasting four hours or more. The elderly are more prone to developing thromboembolic disease, particularly if they also smoke or have mobility problems, cardiovascular or malignant disease, varicose veins or a variety of other chronic medical problems.

Respiratory problems

Healthy individuals with normal cardio-respiratory function are unlikely to be adversely affected by the lower cabin pressure in an aircraft, but those with impairment of function, particularly chronic obstructive pulmonary disease (COPD), may experience arterial oxygen desaturation suffi cient to cause breathlessness. Symptoms may occur at rest in the presence of severe impairment of pulmonary function or on relatively slight exertion, such as walking about the aircraft, in those less severely affected.

Renal problems

With impaired renal function, elderly travellers may have difficulty in compensating for fluid loss during air travel or in hot climates. This may result in dehydration or renal failure.

Reduced immune function

The elderly, whose immune response to infection is reduced, are more prone to develop infections. This may result not only in illnesses peculiar to their destination, such as travellers’ diarrhoea or tropical infections, but also in an increased susceptibility to more common illnesses — such as colds and influenza.

Legionnaires’ disease (caused by aerosol inhalation from showers and air conditioning units) was first described in elderly members of the American Legion after an unfortunate incident at a conference in Philadelphia in 1976, and it remains more common in the elderly or those with impaired immune function. Many elderly people have reduced levels of gastric acid secretion, and this may make them more prone to gastrointestinal infection.

Cerebral function

Elderly people who have been able to maintain apparently normal cerebral function in their home surroundings, where they have familiar cues and routines to help them to function efficiently, may become confused and disorientated when put into unfamiliar surroundings (for example on admission to hospital). Travel may produce a similar result due to unfamiliar surroundings, food and routines, confusing surroundings in airports, crossing time zones or the general stress and anxiety generated by travelling, looking after baggage, worrying about loss or theft and meeting deadlines.

Musculoskeletal problems

Stiffness and reduced movement of joints may cause difficulty in gaining access to aircraft, trains or buses, and may also predispose the patient to developing thromboembolic disease by reducing mobility during travel. Long periods of reduced mobility during a journey may also exacerbate stiffness and further reduce mobility on arrival.

Medication

Medication regimens may not be complied with during travel. This may occur because of forgetfulness or failing to carry medication on the person or in hand baggage. It may also be deliberate in order to avoid adverse or therapeutic effects such as increased urine output from diuretics, ankle swelling from calcium channel blockers, fatigue from beta-blockers, drowsiness or dizziness. If medication is not taken, symptoms from the underlying condition may well be exacerbated.

Advising elderly travellers

It is important that elderly travellers have a pretravel health and medication check carried out by their GP or practice nurse. Medication regimens can be optimised for ease of use during travel and the importance of compliance should be stressed. For those with conditions — such as diabetes, asthma, angina or epilepsy — where relief or emergency treatment may be needed, a strategy for dealing with exacerbations during travel must be discussed. Travellers should also be advised to carry all routine and emergency medication on the person or in hand luggage, preferably divided between more than one site to reduce the possibility of loss or theft. Patients are legally entitled to carry medications prescribed for them and a copy of the prescription will help to authenticate their right to do so. Current airport regulations stipulate that liquids in containers of more than 100ml capacity are not permitted and any liquids carried must be placed in a sealed plastic bag in the hand baggage. Controlled drugs may present a problem: some countries may not allow their import even if medically prescribed for the person carrying them, and some drugs that are not controlled in the UK, for example codeine, may not be carried into some countries. It is wise for the patient to check with the Embassy or High Commission of the country concerned prior to travel.

Adequate supplies should be carried for the duration of the trip, preferably with additional supplies in case of loss or malfunction of inhaler or injection devices. It may also be possible, during the pre-travel health check, to detect pre-symptomatic conditions and advise on their management.

A literature review conducted by the British Travel Health Association12 produced a list of predisposing factors for travel-related thrombo-embolic disease and a suggested strategy for prevention, summarised in Table 1.

Insurance

One of the most useful services that the travel adviser can provide is advice on adequate insurance cover. Insurance offered at the time of booking a trip is not necessarily adequate for the needs of the elderly traveller, as it may not cover pre-existing medical conditions and is seldom likely to be the most economical available. Self help groups, such as Diabetes UK, or specialised insurance brokers or companies can often improve the level of cover available and can usually provide it more economically. For those patients familiar with using the internet, an online search will locate insurers willing to cover older people. Age Concern may also be able to provide information and Which? magazine occasionally publishes information on travel insurance including best buys for cover for the elderly. The last edition carrying this information was July 2006. Insurance should provide adequate cover for hospital and other medical services and for repatriation in the case of death or serious illness. Repatriation to the UK involving a long journey is not always the best solution for a seriously ill patient as good medical care may be available in the country concerned or in a neighbouring country.

Table 1. Advice on prevention of travellers’ thrombosis

Minimal risk (nil or one risk factor)

  • Exercise the legs when possible and maintain hydration

Low to moderate risk (two or three risk factors)

  • Exercise the legs when possible and maintain hydration
  • Consider using below-knee compression stockings
  • Aspirin 75–300mg daily while at risk

High risk (more than three risk factors)

  • Exercise the legs when possible and maintain hydration
  • Below-knee compression stockings
  • Subcutaneous injections of Minihep (sodium heparin 5000 IU twice daily) or low molecular weight heparin (eg, dalteparin 2500 IU daily or enoxaparin 40mg daily).

Conclusion

While the elderly are at increased risk during travel from diminishing organ function and from pre-existing medical conditions, this should not prevent them from travelling. A pre-travel health and medication check, taking care during travel and taking out adequate insurance cover will help to manage these risks. Therefore, the elderly should be able to travel — as they are doing in increasing numbers — to most of the destinations that younger travellers visit/

References

  1. http://www.statistics.gov.uk (date last accessed: 06.03.07)
  2. Bennett N (ed). Travel Trends. London: The Stationery Office, 2000
  3. D’Paixao RJ, Dewar A, et al. What do Scots die of when abroad? Scottish Medical Journal; 36: 114–6
  4. Reid D, Cossar J, et al. Do travel brochures give adequate advice on avoiding illness? BMJ 1986; 293(6560): 1472
  5. Evers BM, Townsend CM, Thompson JC. Organ physiology of aging. Surgical Clinics of North America 1994; 74(1): 23–9
  6. McClaran SR, Babcock MA, Pegelow DF, et al. Longitudinal effects of aging on lung function at rest and exercise in healthy active fi t elderly adults. Journal of Applied Physiology 1995; 78(5): 1957–68
  7. Lakatta EG. Cardiovascular reserve capacity in healthy older humans. Aging 1994; 6(4): 213–23
  8. Epstein M. Aging and the kidney. Journal of the American Society of Nephrology 1996; 7(8): 1106–22
  9. Ruoppila I, Suutama T. Cognitive functioning of 75 and 80 year old people and changes during a 5 year follow-up. Scandinavian Journal of Social medicine Supp 1997; 53: 44– 65
  10. Evans JG. General medicine and geriatrics, where is the difference? The example of infective disease. Schweizerische Medizinische Wochenschrift (Journal Suisse de Medecine) 1995; 125(40): 1847–54
  11. Ferrari E, Chevalier T, Chapelier A, Baudouy M. Travel as a risk factor for venous thromboembolic disease: a case control study. Chest 1999; 115: 440–4
  12. British Travel Health Association Council. Travellers’ thrombosis. Journal of BTHA 2001; 2: 10– 15