Preparing for Take-Off: Readying Older Adults for Flight

Older adults are at risk for a host of potential medical issues while traveling, arising from cognitive impairments such as Alzheimer disease, dementia or psychiatric disorders, and chronic conditions such as cardiovascular disease, diabetes, and incontinence. Most airplanes are not “travel friendly” for older adults who require assistance moving throughout airplane cabins, or who cannot independently toilet. In addition, in-flight personnel are generally not trained to address medical episodes that occur during air travel. To fill this gap, medical travel companies have taken steps to raise awareness of issues that may arise when older adults fly, and offer services such as professional traveling companions and assistance during relocation. The preparatory precautions detailed in this column serve to raise awareness of the specific needs to older adults during travel among all stakeholders and can be used to avoid preventable medical emergency that may occur. 

The potential for medical issues for older adults while traveling is growing, a result of both increased access and demand for far-flung travel and an explosion in the number of frail and older adults. More than 5 million Americans are currently living with Alzheimer disease, a figure expected to rise to 16 million by 2050.¹

As a result, the aviation industry has identified Alzheimer disease as the fastest growing concern for both airports and airlines. Despite this, flight crews are only trained to ensure the safety of the aircraft during flight. They do not have a broader understanding of dementia or specific training in how to address disease-related episodes, making disorientation, hallucinations, wandering, and aggression a true concern.

The number of reports of individuals wandering away from gates and/or airports has increased. Transportation Security Administration agents are not trained to manage travelers with memory impairment during screening. Airlines have described their responsibility as simply escorting passengers requesting assistance through security to their gate or to an Airlines Transfer desk where they may wait on their own. The airline staff cannot stay with a passenger at all times or guarantee supervision at all points of the journey. 

Beyond limits on managing solo travelers with Alzheimer disease, airline and special assistance personnel are not permitted to assist with activities of daily living, increasing the risk for injuries. The risk for falls increases in restrooms. Special assistance personnel wait outside of the restroom with the wheelchair; the traveler walks unassisted into the restroom or is required to self-propel. Restrooms within the airplane itself are small and most often do not provide grab bars. For these reasons and others, traveling alone for frail older adults can be a challenge.

Medical Travel Companions

Assistance is available for older travelers. One of several groups providing travel assistance to older adults is Travel Care, LLC. This company, like many in this space, provides affordable door-to-door companion services for medically stable individuals unable to commercially travel alone. The starting point for this travel can be directly following a discharge from hospital, skilled nursing facility, long-term care facility, assisted living or other retirement community, or a private residence.

These trips are coordinated around each traveler’s individual needs and desires, allowing families and friends to participate in the travel planning. For travelers known to have a history of behavioral expressions, care is given in identifying techniques and approaches that will limit the need for medication and the risk of flight crew concerns during the actual flight. The coordination of these flights—which are typically for relocation rather than vacation—can sometimes take weeks to plan to ensure the safety of the traveler and other airline passengers.

Nurses also assist in the management of chronic medical conditions, such as diabetes, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and incontinence. This includes the maintenance and care of peg-tubes, Foley/suprapubic catheters, medications, oxygen and small volume nebulizer breathing treatments. Communication between the discharging and receiving facilities and family is vital in ensuring a smooth transition. The expertise of these professionals also includes the understanding of rules and regulations, allowing Travel Care’s team to provide assistance in required transition documentation. To establish a personalized care plan, each individual’s travel needs are evaluated by a provider team, who design a care plan to limit the amount of stress for both the traveler and their family. Family and/or friends are actively involved in the planning process. This assistance is available to both prepare the frail older adult to travel and to directly assist during travel.

Care in the Air

Between 2002 and 2005, studies showed that the rate of in-flight deaths doubled.² This is consistent with a study that reported the rate of medical emergencies on commercial flights nearly doubled between 2000 and 2006, from 19 to 35 per 1 million passengers.³ While cardiac issues account for a majority of in-flight deaths, vasovagal syncope—a temporary loss of consciousness—is the most common in-flight emergency.⁴ The Flight Safety Foundation studied in-flight medical care aboard selected US air carriers from 1996 to 1997 and recorded 1132 medical incidents, of which 22.4% were caused by vasovagal syncope, 19.5% by cardiac events, and 11.8% by neurologic events.⁵ In contrast, a study of in-flight emergencies on British Airways flights reported a different pattern of diagnoses, finding that 25% were related to gastrointestinal problems, and fewer than 10% each were from cardiac, neurologic, or vasovagal issues.⁶

In a 1991 Federal Aviation Administration (FAA) study, physician travelers were available in 85% of reported in-flight medical emergencies.⁷ Despite this availability, many physicians remain confused about the law. To begin, the law governing any event happening on an aircraft is usually the law of the country in which the aircraft is registered, except when the aircraft is on the ground. For the United States, the actions of volunteer physicians are described in the Aviation Medical Assistance Act of 1998.⁸ The legislation includes provisions limiting the liability of volunteer physicians who attempt to assist with in-flight medical emergencies, as there are examples in which airlines faced litigation when the advice of passenger doctors was deemed to be incorrect. And although physicians are not obligated to volunteer, the World Medical Association International Code of Medical Ethics states that “a physician shall give emergency care as a humanitarian duty unless he/she is assured that others are willing and able to give such care.”⁹  Still, having one’s own medical assistance, instead of relying on the luck of having a willing and able physician on board, is definitely preferred.

Airlines consider physicians who respond to calls for assistance as volunteers, and as such, passenger physicians complement the flight crew rather than override them. As a result, the physician is not expected to perform duties that the flight crew is trained to handle. Cabin crew receive training in a number of emergency skills, including use of automated external defibrillators (AEDs), and are one of several sources of help available to the medical volunteer, who is not expected to work alone. Because only qualified persons can administer drugs, the flight crew may ask for identification to verify credentials, such as a business card or wallet medical card.

Onboard Medical Equipment

When a medical emergency does occur on board, there is equipment to assist. The Aviation Medical Assistance Act of 1998 set out to direct the administrator of the FAA to reevaluate the equipment contained in medical kits carried by commercial airlines, and to make a decision regarding requiring AEDs to be included.⁸ On April 12, 2001, in response to the Act, the FAA issued a final rule requiring airplanes that weigh more than 7500 pounds and have at least one flight attendant to carry AEDs and enhanced emergency medical kits.¹⁰

Automatic External Defibrillators

Although AEDs are part of the emergency medical kit, many airlines require that only their trained crew operate these devices to ensure continuity of protocols. When use of an AED is required onboard, volunteer physicians should work to complement the skills of the trained crew. Although used infrequently, the presence of these devices on flights is essential, because they can have a dramatic impact on outcomes. The effectiveness of AEDs in flight was described in a study by Page and colleagues,¹¹ who reported that between June 1, 1997, and July 15, 1999, one US airline carrier used an AED on 191 passengers during flights, as well as nine people in an airport terminal. This means the device was used once for every 3288 flights by this carrier. Transient or persistent loss of consciousness was documented in almost 50% of these passengers, with the remaining persons having needed the device primarily because of chest pain. Ventricular fibrillation was electrocardiographically documented by the AED in a total of 14 individuals, and the device terminated every episode with the first shock in 13 of these individuals (defibrillation was withheld in one individual per the family’s request). The rate of survival after defibrillation to discharge from the hospital was 40%, which compares favorably with the rate of survival to discharge among patients who received a defibrillator shock in other out-of-hospital settings.¹¹ Perhaps the most important point for physicians to consider is that AEDs have been found to be safe when used as a monitor, and in no case in Page and colleagues’ study¹⁰ was an inappropriate shock recommended or delivered.

Enhanced Emergency Medical Kits

Enhanced emergency medical kits have been developed to facilitate emergency care by individuals with rudimentary emergency training, ensuring adequate and appropriate care is provided even in the absence of an experienced health care professional. Before the FAA’s final ruling, the only medication required onboard by the FAA was 50% dextrose, nitroglycerin, diphenhydramine, and epinephrine. A list of items that emergency medical kits are currently required to contain can be found on the FAA’s website.¹²

In-Flight Environmental Considerations

Assessment and treatment of older adults in an aircraft is unique for several reasons. Unlike an emergency situation in a public space on the ground, the availability of diagnostic and treatment resources, access to support via 911 and other emergency responders, and availability of a spacious and stable workspace are vastly limited in flight. In addition to the challenges of working at 30,000 feet, the aircraft is also unique in the types of disease manifestations and physiological changes that result within this environment.

An important environmental condition to keep in mind is that the cabin pressure at cruising altitude is set between 5000 and 8000 feet above sea level, which presents two issues for physicians to consider: hypoxia and gas trapped in body cavities.¹² At cruising altitude, all passengers experience some degree of hypoxia. This is the result of the fact that barometric pressure is 760 mm Hg at sea level, with a corresponding partial pressure of oxygen in arterial blood (PaO₂) level of 98 mm Hg, whereas the barometric pressure is 565 mm Hg, with a PaO₂ of about 55 mm Hg at the typical cabin pressure of 8000 feet.¹³ If these data were to be plotted on the oxyhemoglobin dissociation curve, a 90% oxygen saturation level would be obtained.¹³ Although most healthy travelers can compensate for this amount of hypoxia, this may not be true for some older adults who have a cardiopulmonary disease or anemia. In addition, a passenger experiencing a medical emergency in most cases would benefit from supplemental oxygen.

Many airlines will provide therapeutic oxygen for a small fee, but these arrangements need to be made in advance of travel, and are especially important for those older adults requiring supplemental oxygen when not traveling. Since travelers are not permitted to carry their own oxygen onto flights, obtaining it through the airline is the only option. In addition, individuals requiring continuous oxygen should be cautioned that airlines only provide in-flight oxygen; thus, prior arrangements should be made if continuous oxygen is required. 

As noted earlier in this section, airplane passengers may also encounter issues at cruising altitude due to trapped gas, as gas trapped in body cavities at sea level will expand by approximately 25% at cruising altitude.¹⁴ This may exacerbate such conditions as pneumothorax, pneumocranium, or middle ear pain for passengers with preexisting risk factors. Furthermore, these are diagnoses that may only present themselves at 30,000 feet.

Preparing for Travel

Avoiding an in-flight medical emergency is not only a critical event for the patient, but an expense and a danger for the airlines. The decision to divert an aircraft ultimately falls to the captain, but the captain will likely follow the physician’s recommendation, perhaps with additional input from the ground medical team. Oftentimes, ground medical services are being provided by MedAire, Inc, a company that provides 24-hour medical assistance, training, and medical kits to international jet manufacturers and major airlines. MedAire operates a system called the MedLink Global Response Center, which provides onboard physicians with direct call access to emergency care physicians and other services for managing in-flight medical emergencies. MedLink reported managing 19,000 calls for help annually from its call center, based within the emergency unit of the Banner Good Samaritan Medical Center in Phoenix, Arizona.¹⁵

Despite the availability of services such as MedLink, air-to-ground communication is sometimes difficult. This is primarily because many airlines have removed phones from cabins and secured cockpit doors following the terrorist attacks of September 11, 2001. Today, information is usually relayed by intercom from the cabin to the pilots, who then pass it along to MedLink on the ground. It has been reported that some airlines are using satellite radios on flights over the Pacific Ocean, putting headsets in the cabin so that flight attendants can directly communicate with physicians on the ground.³

The decision to divert an aircraft is not to be made lightly, as it can cost in excess of $100,000.² In addition, the diverted aircraft may sustain damages, such as blowing tires due to an overweight landing. DeLaune and colleagues¹⁶ reported an incidence of 22.6 medical complaints per 1 million passengers and 0.1 deaths per 1 million passengers during a 1-year period. Because diversion can be costly, and most onboard medical emergencies are non–life-threatening, it is uncommon for an aircraft to be diverted. The diversion rate is estimated to be between 8% and 13% of all in-flight medical emergencies.¹⁷

Readying Patients

Ideally, many in-flight emergencies may be prevented with proper preparation. Prevention starts with the health care provider assessing and advising his or her older patients with regard to any preflight medical needs. According to the Aerospace Medical Association (AsMA) Medical Guidelines for Airline Travel, there are many medical conditions that should be addressed in a preflight medical evaluation, including cardiovascular diseases (eg, angina pectoris, congestive heart failure, and myocardial infarction [MI]), deep venous thrombosis (DVT), asthma, emphysema, seizure disorder, stroke, mental illness, diabetes, infectious diseases, and conditions for which the patient has undergone recent surgery or that require surgery.¹³ In a MedAire study, passengers with diabetes, seizure disorders, and cardiovascular and respiratory ailments accounted for approximately 25% of all in-flight deaths, and almost 33% of medically related flight diversions.⁴

Patients at Risk of Cardiovascular Events

Physicians should advise their patients who have had a recent uncomplicated MI not to fly until at least 2 to 3 weeks have passed, and they have resumed their usual daily activities.¹² In contrast, patients who have had a complicated MI should not fly for at least 6 weeks following their MI; those who have undergone coronary artery bypass graft surgery should not fly before 10 to 14 days postoperatively; and those who have had a stroke should wait at least 2 weeks before traveling by air.¹¹ Cardiovascular conditions that present a contraindication to air travel include severe decompensated congestive heart failure, unstable angina, uncontrolled hypertension, uncontrolled ventricular or supraventricular tachycardia, Eisenmenger syndrome, and severe symptomatic valvular heart disease. Mild asymptomatic valvular heart disease presents a relative contraindication to air travel.

According to the AsMA, physicians should make several travel recommendations for their patients with cardiovascular conditions, one of which is that they carry enough cardiac medication for their entire trip, including sublingual nitroglycerin tablets, and keep these medications in their carry on luggage.¹² Another recommendation is that patients keep a list of their medications, including dosage and timing, and adjust dosing intervals to maintain their regular frequency when crossing time zones. Additionally, patients should carry a copy of their most recent electrocardiogram and their pacemaker card if they have a pacemaker. Generally, it is advisable for patients to contact their airline concerning special needs, such as oxygen and wheelchair access, and to consider special seat requests (eg, near the front of the plane, close to the restrooms, or with extra leg room).

Patients at Risk for DVT

Special precautions may also be needed for older adults at especially high risk for developing a DVT, especially if there will be prolonged immobilization due to a long flight (> 6 hours).¹² Although DVT itself is not a dangerous condition, it can have life-threatening complications, such as pulmonary embolism or venous thromboembolism. There are numerous factors besides a patient’s age that may put him or her at risk for developing a DVT. These risk factors include blood disorders that affect clotting tendency, cardiovascular diseases, current malignancy or history thereof, recent major surgery or trauma to the lower limbs or abdomen, and a personal or family history of DVT. For such individuals, possible preventive options include taking aspirin or low-molecular-weight heparin, depending on the level of risk, and wearing compression stockings.

Patients With Diabetes

Although airline travel should not pose a significant problem for patients whose diabetes is normally well controlled, proper preparation remains beneficial. Besides recommending that diabetic patients pack enough supplies to test their blood glucose levels for the duration of their trip, physicians can make other specific recommendations to their patients.¹¹ For example, they should advise individuals who normally take insulin once daily before breakfast to take their standard dose at the usual time of the day, regardless of whether travel is east or west. For diabetic individuals traveling east across time zones, upon arrival, will have a shorter day, and so it may be necessary to take fewer units of insulin. While traveling west across time zones, the individuals’ day will be longer, and they may require additional insulin injections or an increased dose of an intermediate-acting insulin. It is a good idea for individuals with diabetes to have their wristwatch unadjusted during flight so that it shows the time at the point of departure, making it easier to judge the spacing between meals. Also, if needed, special diabetic meals should be requested well in advance of the travel date.

Patients With Psychiatric Disorders

Persons with psychiatric disorders that lead to unpredictable and aggressive behaviors should not travel by air until those behaviors are well controlled, as these individuals can pose a danger or be disruptive to others onboard. Generally, patients with a psychiatric disorder can become upset by the common irritations of travel, such as crowding with strangers, lack of privacy, and delays.¹¹ If a patient with a psychiatric disorder, such as dementia, must travel by air, a capable and knowledgeable flight companion (ie, a caregiver or family member) should accompany him or her. Physicians can offer the patient and his or her travel companion several travel recommendations.¹² For example, since patients with dementia often experience sundowning syndrome (ie, an increase in abnormal behaviors at a certain time of the day, typically in the late afternoon, evening, or night), the timing of flights should be taken into account to avoid the patient being in the air during this time. As for prescribing a medication to a patient to assist with behavior, it has been recommended that one never prescribe a medication for in-flight use unless the patient has used it before and is familiar with its effects. Obviously, during a flight is no time to discover an untoward medication reaction.

Patients With Less Complex Disorders

Physicians can also make useful recommendations to ensure the comfort of their traveling geriatric patients with disorders that are not potentially dangerous, but that can pose a nuisance, such as hearing impairment and urinary frequency or incontinence. Patients with hearing aids may become frustrated by their decreased ability to hear in flight due to background noise in the cabin. These patients should be advised to turn their hearing aids down, because high volume reduces sound discrimination. As for those with urinary frequency or incontinence, an aisle seat, preferably close to the restrooms, is advised. If the patient’s urinary frequency is related to a medication, such as a diuretic, dose adjustments may be warranted. Patients with urinary incontinence may consider wearing and packing additional absorbent pads or wearing a portable urinary catheter. Although it is important for patients to stay hydrated during their flight, they should be reminded that not all beverages are created equal. Water is the best choice. Caffeinated beverages (eg, coffee, soda, tea) and alcohol are diuretics, and can aggravate an already overactive bladder; thus, these should be avoided.

Opportunities

Frail older adults looking to travel have the opportunity to properly prepare which can include the assistance of a medical travel companion. This is especially critical given that an increasingly aging population is taking to the skies. It is therefore vital for a variety of geriatric health care providers to be well versed both in preparing older adults for air travel, and in being ready to respond to medical emergencies that occur on aircraft—although the real opportunity is in preventing these from occurring in the first place, so that everyone can enjoy a safe trip.

For additional information on preparing older adult patients for air travel, there are two especially helpful resources that have been prepared by the AsMA. These include Useful Tips for Airline Travel and Medical Guidelines for Airline Passengers, which are both available through their website at www.asma.org. 

References

1.    2016 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association website. https://www.alz.org/documents_custom/2016-facts-and-figures.pdf. Accessed March 22, 2017

2.    Cocks R, Liew M. Commercial aviation in-flight emergencies and the physician [published correction appears in Emerg Med Australas. 2007;19(3):286]. Emerg Med Australas. 2007;19(1):1-8.

3.    Davis R, DeBarros A. In the air, health emergencies rise quietly. USA Today. March 11, 2008. www.usatoday.com/news/health/2008-03-11-inflight-medical-emergencies_N.htm. Accessed March 22, 2017.

4.    Qureshi A, Porter KM. Emergencies in the air. Emerg Med J. 2005;22(9):658-659.

5.    DeJohn C, Veronneau S, Wolbrink A, Larcher J, Smith D, Garrett JS; Flight Safety Foundation. Evaluation of in-flight medical care aboard selected US air carriers: 1996-1997. Cabin Crew Safety. 2000;35(2):1-19. https://flightsafety.org/ccs/ccs_mar_apr00.pdf. Accessed March 22, 2017.

6.    Dowdall N. “Is there a doctor on the aircraft?” Top 10 in-flight medical emergencies. BMJ. 2000;321(7272):1336-1337.

7.    Hordinsky JR, George MH; US Department of Transportation. Utilization of Emergency Kits by Air Carriers. Washington, DC: Office of Aviation Medicine, 1991. https://bit.ly/EmergencyReport. Accessed March 22, 2017.

8.    Aviation Medical Assistance Act of 1998, HR 2843, 105th Cong (1998). medaire.com/FAA_OnboardMedicalKits_pl105170.pdf. Accessed March 22, 2017.

9.    World Medical Association. WMA International Code of Medical Ethics. wma.net/en/30publications/10policies/c8/. Published 1949. Accessed March 22, 2017.

10.    Federal Aviation Adminstration. FAA requires airlines to carry heart device [news release]. Washington, DC: US Department of Transportation; April 12, 2001. www.faa.gov/news/press_releases/news_story.cfm?contentKey=1262. Accessed March 22, 2017.

11.    Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a US airline. N Engl J Med. 2000;343(17):1210-1216.

12.    US Department of Transportation; Federal Aviation Administration. Emergency medical equipment. Advisory Circular No. 121-33. rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.ns...$FILE/AC121-33.pdf. Accessed March 22, 2017.

13.    Aerospace Medical Association Medical Guidelines Task Force. Medical Guidelines for Airline Travel, 2nd ed. Aviat Space Environ Med. 2003;74(suppl 5):A1-A19.

14.    Porter RS, Kaplan JL, eds. Air travel: medical aspects of travel. The Merck Manual Online. merckmanuals.com/professional/special_subjects/medical_aspects_of_tr. Accessed March 22, 2017.

15.    MedAire. About MedLink, a service of MedAire. medaire.com/MedAire_AboutMedLink.pdf. Accessed March 22, 2017.

16.    DeLaune EF, Lucas RH, Illig P. In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med. 2003;74(1):62-68. www.merckmanuals.com/professional/special_subjects/medical_aspects_of_tr.... Updated February 2009. Accessed March 22, 2017.

17.    Gårdelöf B. In-flight medical emergencies. American and European viewpoints on the duties of health care personnel [in Swedish]. Lakartidningen. 2002;99(37):3596-3599.