Recurrent/Protracted Travel

Being at a distance from their regular healthcare providers is both a source of increased risk and anxiety for those recurrently on the road. Medication regimens, ongoing medical problems, and even the increased statistical risk of a new medical event raise the stakes when far from home in an unfamiliar or inadequate healthcare system. For these reasons preparation for foreign travel by those with significantly cumulative time abroad must be deliberate and comprehensive. This is even more so for those over 50 years-old or with active medical problems, even if stable on treatment.

1. Routine Measures
   1. Pre-Travel Physical Conditioning: Most travel will require extraordinary labor and walking. 3 - 4 weeks prior to departure a routine of walking, leg strengthening, and flexibility exercise is advisable.
   2. Pre - Trip Medical Exam / Documents:
      1. Targeted exam – by a physician to assure medical fitness
      2. Medical Record Copies – pertinent information; especially consider carrying a copy of the most recent electrocardiogram (EKG) (even as a PDF on an electronic device or in "Evernotes")
      3. Physician’s Clinical Summary Letter – including medication dosages (especially controlled substances) and a statement on the medical necessity of any syringes and needles to be carried
      4. MedicAlert bracelet or necklace, as appropriate, for diseases, allergies, etc.:MedicAlert FoundationP.O. Box 1009Turlock, CA 95381 - 10091-800-432-5378
   3. Medications:
      1. Take enough meds for the entire trip duration, plus several weeks (may not find medicine equivalents overseas).
      2. If need to purchase meds overseas, always try to use same manufacturers as at home.
      3. Be sure to transport meds to preserve potency, especially in hot climates (do not pack in luggage to be in cargo bay).
      4. Consider listing medications and dosage schedules on personal computer at home to enable Internet access from anywhere, along with other key healthcare information, such as physicians’ e-mail addresses, phone numbers, etc.
   4. Insurance:
      1. Medicare does not cover care outside the U.S.
      2. It is necessary to purchase med-gap coverage or a separate health insurance policy. Consideration should also be given to coverage for medical evacuation or repatriation of a body in the case of death en route.
      3. Note: Store a hair sample for DNA analysis in a dry container and instructions on its locations.
2. Medical Travel KitsIn the event of illness or injury, a medical kit allows for self-medication until it is determined whether the traveler should return home for definitive care, or continue on without foreign medical care system entry.
   1. Medications to be considered for,
      1. Fever
      2. Motion sickness
      3. Gastrointestinal illness
      4. Respiratory symptoms
      5. Mild to moderate pain
      6. Skin infection
      7. Aspirin and nitroglycerin: since cardiovascular (stroke, heart attack) events pose the greatest risk to traveling elders.
      8. Anti-malaria meds: where appropriate, per destination
3. ImmunizationsVaccine recommendations for those over 65 years old are the same as those for younger travelers, except that influenza, shingles, and pneumococcal (bacterial) pneumonia vaccines are often indicated whether in the U.S. or overseas.
4. Acclimatization
   1. Heat - Cardiovascular disease or diabetes mellitus may impair adaptation to excessive heat. Likewise, a number of medications can interfere with body temperature responses: beta-blockers, calcium-channel blockers, antidepressants, antihistamines, and Parkinson drugs (slow heat adjustment).
   2. Cold - Hypothermia risk increases with age; clothing must take this into account.
   3. Altitude - Elderly travelers must avoid rapid ascent to high altitude and be aware that above 8,000 feet anemia, cardiovascular disease, and lung disease may cause serious physical impairment and performance deterioration. Also, beta-blockers may interfere with the natural adjustment of heart rate (increase) to low oxygen at high altitude, resulting in a seriously risky physical state if there is underlying disease.
   4. Dysentery - This must be dealt with aggressively, especially in elderly individuals who are often on vital medications; the rapid bowel transit times associated with diarrhea may impair or prevent absorption of meds from the GI tract, putting them at risk for being virtually "un-medicated".
   5. Motion Sickness - Scopolamine transdermal patches are routinely prescribed for motion sickness prevention and treatment; in elderly patients it may cause severe constipation, urinary retention, and/or mental confusion.
5. Special Considerations
   1. Foot Care – some travelers may have poor arterial circulation in the feet or sensory nerve impairment from diabetes or other disorders. The increased walking during a trip can result in infections, non-healing soft-tissue ulcers, stress fractures, etc. Even a relatively short trip can lead to long-term or permanent problems threatening mobility.
   2. Key Points:
      1. No bare feet, ever, with diabetes mellitus; inspect feet twice a day (carry a small mirror for the bottoms).
      2. Never break-in new shoes on a trip; wear footwear, especially that for intense walking/hiking, several weeks pre-departure.
      3. Change socks twice daily.
      4. In humid regions, consider topical anti-fungal powders preventively.
      5. Carefully select your working/walking footwear for function rather than style.
      6. At the first appearance of reddened areas on the feet suggesting tissue reaction to trauma, adjust or change footwear, or see a physician or podiatrist.
   3. Vision
      1. Take extra eyeglasses and/or contact lenses.
      2. Take extra contact lens cleaner fluid; remember that water purified with iodine may stain lenses brown.
      3. Carry a copy of your eyewear prescription.
   4. Hearing
      1. Take extra hearing-aide batteries.
   5. Dental
      1. Carry extra denture adhesive; it may be difficult to find overseas.
   6. Special Diets
      1. Those with diabetes, heart disease, high blood pressure, kidney disease, etc. may require special diets (order ahead from airlines)
      2. Airlines must be notified 1–2 days pre-departure of medical restrictions and requirements.
   7. Chronic Disease Travel Groups
      1. Medical societies and specific disease organizations (i.e. American Diabetes Association) can provide information on travel groups comprised exclusively of individuals afflicted with the disease so as to accommodate all their special needs.
   8. IAMAT
      1. The International Association for Medical Assistance to Travelers (Ontario, Canada) provides lists of foreign, English-speaking physicians who are considered medically qualified practicing at foreign locales and at reasonable prices.
   9. Portable Oxygen
      1. Airlines may or may not accommodate a medical condition requiring supplemental oxygen in transit. Implementing this is laborious, often taking 3-4 weeks to arrange. It is probable that the following issues will pertain:
         1. Airline will probably require independently arranged oxygen supply in place up to the time of boarding and at the disembarkation point.
         2. Physician Order – airline will probably require a notarized order conforming to an established protocol specific to the airline. Additionally, the airline may require an audiotaped brief interview with the physician verifying his orders.Note: If you have had any recent change in your medical condition, such as surgery, review this with your physician or travel medicine specialist prior to departure.
6. Post - Travel Medical Examination
   1. If an individual has been overseas for over 3 months or suffered illness or injury during their trip, it is wise to consider a brief check-up with a physician upon return home. If there had been fever, diarrhea, or other unexplained persistent or protracted medical problems associated with traveling, medical evaluation is advisable. If travel included exotic or developing countries, a qualified travel medicine specialty physician evaluation may be of value.

Edward R. Rensimer, MD, FACPDirector