TY - JOUR
AU - Bischoff-Ferrari, Heike, A
AB - Abstract Background The worldwide prevalence of dementia is increasing and represents a major public health concern. In the last decades, air travel services have undergone an impressive expansion and one of ten passengers is aged 65 years and older. While air travel can be stressful at all ages and health conditions, older individuals with cognitive impairment carry a greater risk for air-travel-related complications. Consequently, demands to general practitioners for assessing their older patient’s fitness to fly are increasing. Methods We conducted a search of the literature in PubMed on the impact of in-flight environmental changes on passengers with cognitive impairment and possible resulting complications. This set the base for a discussion on pharmacological and non-pharmacological interventions aimed at preventing in-flight complications in this vulnerable population. Results While our research strategy identified a total of 11 articles related to older age and air travel, only three focused on passengers with cognitive impairment. Our literature review showed that the airplane environment may lead to a large spectrum of symptoms in passengers of all age groups. However, passengers with cognitive impairment due to neurodegenerative diseases are at increased risk for experiencing the most extreme symptoms such as acute confusional state. Non-pharmacological and pharmacological interventions at different stages of the travel process (before, during and after) can help prevent complications in this vulnerable population. Conclusion The decision to let a patient with cognitive impairment fly requires a solid understanding of the in-flight environmental changes and their impact on older patients with cognitive impairment. Moreover, a sound weighing of the risks and benefits while considering different aspects of the patient’s history is demanded. In this regard, the role of the treating physicians and caregivers is essential along with the support of the medical department of the airline. Mental health, Older passenger, Traveller mental health, Dementia, Pre-travel advice, Medication, In-flight medical emergencies Introduction According to the International Air Transport Association (IATA), more than 4 billion air travel journeys were undertaken in 2018.1 International tourist arrivals, from countries with various social, economic and political status, have increased from nearly 25 million in 1950 to more than 1 billion in 2015.2,3 In 2019, forecasting models suggested that the number of air travel journeys would likely double by 2037.1 Yet, in 2020, the coronavirus disease (COVID-19) pandemic did affect air travel demands and brought uncertainties for the years to come.4 In the last decades, in order to accommodate the increasing number of passengers and improve the travel experience, new large airports were built, and existing airports extended, some into complex terminal layouts. Air travel can be a stressful event due to lengthy security procedures, prolonged queuing times, long distances between check-in and departure gates, crowded waiting areas and unfamiliar information boards as well as time changes and lack of sleep.5,6 Furthermore, the implementation of preventive measures in airports and aircrafts to limit the spread of infectious diseases, like COVID-19, may further accentuate travel hassle.7 In order to facilitate the flow of passengers, customers are increasingly asked to actively participate into the process of travelling by self-check-in or self-boarding. All these factors may result in considerable stress for cognitively impaired travellers. In-flight medical emergencies (IME) occur approximately 1 per 604 flights.8 The high prevalence of age-related conditions puts older individuals at increased risk for medical emergencies during travel. In a retrospective study using data from the Lufthansa registry of IME, 20 000 medical events were documented on long-haul flights; 7000 (35%) of those events happened in individuals aged 55 years or more.9 Another retrospective study of more than 1000 events occurred on domestic US flights between 1996 and 1997 showed that age is also a risk factor for fatal IME.10 A study based on data from MedAire, a medical resource for airlines, reported that 3.5% of in-flight emergencies were psychiatric, mostly due to acute anxiety.11 Dementia is defined as a progressive decline in cognitive function leading to a loss in independence during everyday activities. Alzheimer’s Disease (ad) is the most frequent form of dementia, followed by vascular dementia (VaD).12 Prodromal stages of dementia are characterized by milder alterations, which allow individuals to keep most of their functional independence.13,14 According to the Global Burden of Disease Study 2016, the worldwide prevalence of dementia reaches almost 44 million, with an age-standardised prevalence of 712 per 100 000 population.15 Passengers with various stages of cognitive impairment may therefore represent a substantial proportion of older passengers. In recent years, newspapers reported unfortunate incidents of passengers with dementia who got lost while travelling.16,17 Appropriate identification of the risk factors associated with air-travel-related complications in patients with impaired cognitive function and dementia is therefore essential. In the last decades, leaders from airline industries have become increasingly aware of passengers with dementia. Airports, such as London Heathrow and London Gatwick, have worked in joint collaboration with the UK Alzheimer’s Society to develop special lounges to accommodate patients with dementia and have trained their staff on dementia.18,19 Some airlines provide specific guidance for passengers with cognitive impairment.20,21 Treating physicians, particularly primary care providers, are often the first resource for pre-travel advice.22 While guidelines have been published by various medical associations regarding the management of patients with cardiovascular and respiratory diseases, evidence-based and state-of-the-art recommendations for patients with dementia are lacking.23,24 Thus, a proper understanding of the in-flight environmental changes together with the different challenges faced by a patient with dementia is critical; this allows treating physicians to assess their patient properly and provide appropriate guidance. In addition, travel medicine practitioners and the airline’s medical department can further support the decision-making. The aim of this review is to identify and discuss the challenges associated with air travelling for older individuals with different stages of cognitive impairment and offer practical pre-travel recommendations for patients and caregivers. Methods We conducted an online search of PubMed from inception to April 2020 with the aim of identifying appropriate literature related to older adults and air travel. Following terms were used in the search strategy ‘old’, ‘older’, ‘elderly’, ‘dementia’, ‘cognitive impairment’, ‘air travel’, ‘physiological changes’, ‘cognition’ and ‘aerospace medicine’. Articles were screened by titles and abstracts by the reviewers (A.S., G.F.). Papers written in English, French and German were considered. Articles that were not accessible in full text were excluded. We also screened for the same search terms within the references of the articles selected in the primary search. Finally, we also reviewed documents published by the International Air Transport Association (IATA), the UK Department of Transport Civil Aviation Authority, US Federal Aviation Administration and Aerospace Medical Association as well as the Alzheimer’s Association. Results Our search strategy yielded a total of 11 papers related to older adults and air travel. Only three of them, all single patient case-reports, addressed precisely the issue of cognitive impairment and fitness to fly in this subpopulation.25–27 In addition, we identified 45 studies reporting in-flight physiological changes and their effects in younger healthy individuals. Due to the lack of studies conducted in older passengers with cognitive impairment, we will discuss the possible influence of in-flight stressors on these passengers based on the evidence from younger individuals. A summary of symptoms in patient with cognitive impairment can be found in Figure 1. Figure 1 Open in new tabDownload slide Effect of in-flight environmental changes in patients with cognitive impairment. Cabin pressurisation is kept at an altitude between 1525–2438 m (5000–8000 feet). Lower cabin humidity and pressurisation lead to fluid loss, moderate hypoxia and gastric distention in passengers. Subjects with cognitive impairment show baseline alteration in brain metabolism, which combined to other risk factors, may potentiate these effects. The spectrum of symptoms can be of various severity Figure 1 Open in new tabDownload slide Effect of in-flight environmental changes in patients with cognitive impairment. Cabin pressurisation is kept at an altitude between 1525–2438 m (5000–8000 feet). Lower cabin humidity and pressurisation lead to fluid loss, moderate hypoxia and gastric distention in passengers. Subjects with cognitive impairment show baseline alteration in brain metabolism, which combined to other risk factors, may potentiate these effects. The spectrum of symptoms can be of various severity Effect of moderate hypoxia on brain metabolism In most modern aircrafts the cabin pressure corresponds to 2400 m altitude (8000 ft). At this level, the reduction in atmospheric pressure leads to a fall in oxygen saturation up to 90–93%.28 For practical reasons, it is difficult to investigate these changes’ effect on brain metabolism in flight. Studies conducted in healthy younger individuals living at moderate to high altitude show changes in glucose metabolism in specific brain regions as well as a compensatory increase in cerebral blood flow to keep the global oxygen delivery constant.29–31 In healthy subjects, these changes may already result into dizziness, nausea and headache. Symptoms in patients with cognitive impairment, ad and VaD may be more severe as a decrease in cerebral blood flow in regions affected by neurodegeneration is already noted at baseline.32–34 Furthermore, respiratory comorbidities resulting in a lower arterial oxygen pressure may amplify clinical symptoms, which may range from disorientation, agitation and anxiety up to the state of delirium. In long-haul flight, extended exposure to low pressure in oxygen may further increase this risk. Case reports among older adults of post-flight confusion after long-haul flights suggest that there may be extended effects on brain function among this target group with a possible delay between the onset of cerebral hypoperfusion and first symptoms.25,26 Gas volume expansion may precipitate delayed gastric emptying Following Boyle’s law, gas expansion within air-filled cavities such as the intestines and middle ears, may reach up to 35% at 2438 m (8000 feet) altitude.35 These physiological changes may result into gastric distension and delayed gastric emptying in healthy subjects.36 In passengers with dementia, these effects may further accentuate pre-existing gastroparesis, resulting from the accumulation of aberrant proteins in regions involved in autonomic functions.37 This may lead passengers to reduce their in-flight food and liquid intake hereby increasing the risk for dehydration and subsequent drop in blood pressure.38,39 The latter may eventually lead to syncope, a common in-flight complication.8,40 Also, the discomfort and pain associated with these symptoms may trigger anxiety and agitation, which may amount to delirium, as reported in studies conducted in hospital setting.41 Beyond gastroparesis, chewing and swallowing difficulties increase eating duration in patients with dementia, which can reach up to 35 min and is influenced by the exposure to light and noise.42 Depending on the travel class and the duration of the flight, the time of meal service is often pre-given, and the time allocated to eat might be shorter than 30 min. Furthermore, the environment might be much more distracting and cramped than at home, thereby further complicating food intake. Ear pain resulting from changes in air pressure leads to discomfort, and may be accompanied by other unpleasant symptoms such as tinnitus and hearing disturbances, which can in some cases aggravate pre-existing hearing difficulties and may enhance distress in patients with dementia.43 Dehydration resulting from cabin humidity increases the risk for acute confusional state Cabin humidity can drop to 5–20% and result in fluid loss and dehydration.44,45 Studies suggest that dehydration may become symptomatic 3 to 4 hours after exposure.46 In healthy subjects, reduced cognitive function in domains such as spatial cognition and vigilance were noted at fluid loss of 1–3%.47 Symptoms are likely to be more severe in patients with cognitive impairment. In hospital settings, dehydration increases the risk of acute confusional state in patient with dementia.48 The concomitant intake of diuretics and reduced fluid intake may further precipitate dehydration. Furthermore, dehydration combined with pre-existing dementia related autonomic dysfunction put passengers with dementia at increased risk for orthostatic hypotension and falls, during the flight or while disembarking. Noise and enclosed space may result in distress in patients with dementia Daily routine and a familiar environment play a beneficial role in patients with dementia. Disruption of this routine can lead to severe distress and result in delirium in acute care.49 When travelling on airplanes, daily routine is broken, familiar landmarks are lost and stressors are increased. Similar conditions trigger fear of flying phobia independent of age.50 A retrospective study of 200 flights showed that passengers were exposed 75% of the flight duration to sounds exceeding the recommended 80 dB (A) threshold.51 Continuous exposure to harmful noises may lead to distress especially in patients with dementia as their brain functions are more vulnerable compared with healthy adults.52 Increased environmental noises are likely to reduce the ability of passengers with dementia to communicate with accompanying caregivers who could provide reassurance. Additionally, the extended entrapment in an enclosed space can precipitate reactions ranging from anxiety, agitation or reduced arousal among older adults with dementia.50 Considering that reduced mobility is a predisposing factor of delirium, it is likely that the reduced leg space may have similar effects.53 Finally, noise and reduced space are likely to interfere with a passenger’s sleeping habit and increase the risk for jet lag. Studies in hospitalised patients suggest that the use of earplugs and eye-masks improves sleep quality and reduces the risk of delirium.54,55 Evidence in passengers with cognitive impairment are needed. Jet lag and the risk for delirium Jet lag is defined as a misalignment of the physiological circadian rhythm.56 Several factors related to air travel contribute to the development of jet lag such as, crossing time zones, dehydration, sleep loss and reduced mobility. The consequences of jet lag on the human body can range from sleep disturbances to psychomotor deficits and mood changes.57,58 In the last decades, reports from animal and human studies suggest that chronic exposure to jet lag might increase the risk for neurodegenerative diseases.59–61 So far, no study has investigated the impact of jet lag on patients with dementia. Though it is well documented that in patients with mild to severe form of ad, the circadian rhythm is disturbed resulting in an increase in sleep during daytime.62 It is therefore possible that the effect of jet lag might aggravate the sleep disturbances in these passengers and may lead to agitation during flight and sleep disturbances post-flight with longer periods for resynchronisation.25–27 Dementia: a barrier to flying? Recently, dementia awareness campaigns stressed the importance of including patients with dementia in our society and travelling may allow these patients to remain members of a family, participate in leisure activities or enjoy vacation time.63 The rights for passengers with disabilities and reduced mobility when travelling by air are described in the regulation (EC) No 1107/2006 of the European Parliament and of the Council and Section § 382.111 of the Department of Transport in the USA.64,65 Previous regulations also provide a list of services a carrier must provide to passengers with disability on board of an aircraft, including use of lavatory. However, while flying may support psycho-social benefits in patients with mild to moderate forms of dementia, flying can have deleterious effects in patients with advanced stages of dementia, and a thoughtful weighing of the risks and benefits should be discussed with the family and caregivers. Most importantly though, travel preparations should be made well in advance. This allows enough time to take the appropriate steps to prepare the journey as outlined below. Practical recommendations Large epidemiological studies show that older travellers have higher prevalence of chronic conditions before travelling and are at higher risk of developing life-threatening conditions when traveling.66–69 Recently, guidelines for the prevention of travel-associated illnesses in older individuals have been published.70 Although some of these may apply to air travel, specificities in terms of environmental and physiological constraints associated with flying require additional aspects to be taken into consideration. Moreover, these guidelines refer to recommended vaccines and studies focusing mainly on cardiovascular and pulmonary comorbidities and not on cognitive impairment. In this regard, the Alzheimer Association provides some useful general advice on its website.71 Other authorities such as the Aviation Consumer Protection from the US Department of Transportation offer guidance for passengers travelling with a disability. An overview of useful websites for medical professionals as well as patients and caregivers is found in Table 1. Table 1 Useful websites providing guidance for travellers with cognitive impairment For medical professionals UK Department of Transport Civil Aviation Authority Guidance for health professionals on assessing fitness to fly for patients with psychiatric conditions https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Guidance-for-health-professionals/Psychiatric-conditions/ Aerospace Medical Association Medical considerations for airline travel Air travel of passengers with neurological conditions https://www.asma.org/publications/medical-publications-for-airline-travel/medical-considerations-for-airline-travel US Federal Aviation Administration Passenger Health and Safety Comprehensive Medical Topics https://www.faa.gov/travelers/fly_safe/health/comprehensive/ For medical professionals, patients and caregivers Alzheimer’s Association Traveling advice for passengers with Alzheimer’s or another dementia https://www.alz.org/help-support/caregiving/safety/traveling US Department of Transportation Aviation Consumer Protection Traveling with a disability https://www.transportation.gov/individuals/aviation-consumer-protection/traveling-disability For medical professionals UK Department of Transport Civil Aviation Authority Guidance for health professionals on assessing fitness to fly for patients with psychiatric conditions https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Guidance-for-health-professionals/Psychiatric-conditions/ Aerospace Medical Association Medical considerations for airline travel Air travel of passengers with neurological conditions https://www.asma.org/publications/medical-publications-for-airline-travel/medical-considerations-for-airline-travel US Federal Aviation Administration Passenger Health and Safety Comprehensive Medical Topics https://www.faa.gov/travelers/fly_safe/health/comprehensive/ For medical professionals, patients and caregivers Alzheimer’s Association Traveling advice for passengers with Alzheimer’s or another dementia https://www.alz.org/help-support/caregiving/safety/traveling US Department of Transportation Aviation Consumer Protection Traveling with a disability https://www.transportation.gov/individuals/aviation-consumer-protection/traveling-disability Open in new tab Table 1 Useful websites providing guidance for travellers with cognitive impairment For medical professionals UK Department of Transport Civil Aviation Authority Guidance for health professionals on assessing fitness to fly for patients with psychiatric conditions https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Guidance-for-health-professionals/Psychiatric-conditions/ Aerospace Medical Association Medical considerations for airline travel Air travel of passengers with neurological conditions https://www.asma.org/publications/medical-publications-for-airline-travel/medical-considerations-for-airline-travel US Federal Aviation Administration Passenger Health and Safety Comprehensive Medical Topics https://www.faa.gov/travelers/fly_safe/health/comprehensive/ For medical professionals, patients and caregivers Alzheimer’s Association Traveling advice for passengers with Alzheimer’s or another dementia https://www.alz.org/help-support/caregiving/safety/traveling US Department of Transportation Aviation Consumer Protection Traveling with a disability https://www.transportation.gov/individuals/aviation-consumer-protection/traveling-disability For medical professionals UK Department of Transport Civil Aviation Authority Guidance for health professionals on assessing fitness to fly for patients with psychiatric conditions https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Guidance-for-health-professionals/Psychiatric-conditions/ Aerospace Medical Association Medical considerations for airline travel Air travel of passengers with neurological conditions https://www.asma.org/publications/medical-publications-for-airline-travel/medical-considerations-for-airline-travel US Federal Aviation Administration Passenger Health and Safety Comprehensive Medical Topics https://www.faa.gov/travelers/fly_safe/health/comprehensive/ For medical professionals, patients and caregivers Alzheimer’s Association Traveling advice for passengers with Alzheimer’s or another dementia https://www.alz.org/help-support/caregiving/safety/traveling US Department of Transportation Aviation Consumer Protection Traveling with a disability https://www.transportation.gov/individuals/aviation-consumer-protection/traveling-disability Open in new tab General considerations First, we recommend enquiring about previous flying experience. This will help identifying passengers at risk for acute mental distress, such as patients who have never flown before, or patients who suffered from flying phobia before the onset of cognitive impairment.72 Second, the presence of a caregiver who will accompany the passenger is highly recommended. Although airline companies and airports can provide special assistance, the presence of a familiar face is likely to reduce the level of anxiety significantly. Moreover, if the passenger is not able to follow safety instructions, airline companies require the presence of an accompanying healthy adult. Additionally, a caregiver might also be able to sense well in advance first symptoms and signs, which may preclude acute distress thereby allowing to take preventive actions e.g. avoiding triggers. The role of a familiar face in the prevention of agitation and delirium in the hospital setting is well established and caregivers are increasingly involved in delirium prevention programs.73 Third, the timing of travel should be chosen wisely. Patients with cognitive impairment who have been recently hospitalised may be at increased risk for acute mental distress and delirium due to persistent pain, reduced function or newly prescribed drugs.74 Finally, other aspects such as previous history of delirium or agitation in a similar environment or when hospitalised and the type of dementia may be further aspects to take into consideration.75 Non-pharmacological interventions In preparation of the trip, we recommend a series of non-pharmacological interventions, which range from organising the assistance at the departing and arriving airports to optimising the in-flight experience (Table 2). Additionally, we recommend visiting the airline’s website where airline-specific guidance and practical recommendations are provided for passengers with cognitive deficiencies. These steps should be taken well in advance. Table 2 Non-pharmacological recommendations for travellers with cognitive impairment At home  • Check latest states, airlines and airports regulations in case of infectious disease outbreaks (like COVID-19)  • Visit the airlines’ and airport’s website on special assistance (e.g. wheelchair)  • Consider requesting early boarding  • Book a flight time in the late morning or early afternoon in order not to interfere too much with the daily routine  • Whenever possible, book direct flights. If not possible, allow enough time to transfer between two connecting flights. In this case, a wheelchair special assistance is recommended.  • When booking a flight, seats at the aisle and next to the caregiver should be booked and secured in advance.  • Consider a seat reservation close to the lavatories  • Check and book in advance a special meal request adapted to the passenger’s diet At the airports  • Book an assistance at the arriving and departing airports. Airline and airport specific procedures should be checked and followed.  • If possible, allow plenty of time before departure and book a lounge access if available/possible  • Before boarding, appropriate emptying of the bladder will prevent urinary retention or bladder overflow incontinence when the seatbelt sign is on. In patients with known incontinence, urinary pads should be changed before the flight and appropriate changing material organised. In the plane  • Informing the cabin crew about the condition of the patient may help to raise awareness and avoid unnecessary misunderstandings.  • During the flight, appropriate hydration should be ensured. Alcohol consumption should be avoided as this may alter the cognitive function and may trigger anxious states, disinhibition and delirium.  • Excessive consumption of caffeine or tea should be avoided as these may have diuretic effects  • As gastric emptying is reduced during flight, it is better to take small quantities multiple times during the flight. Food rich in fibres should be avoided.  • Ear plugs or eyes shades may be used during the flight  • We recommend accompanying the patient to the lavatories and provide assistance where needed. At home  • Check latest states, airlines and airports regulations in case of infectious disease outbreaks (like COVID-19)  • Visit the airlines’ and airport’s website on special assistance (e.g. wheelchair)  • Consider requesting early boarding  • Book a flight time in the late morning or early afternoon in order not to interfere too much with the daily routine  • Whenever possible, book direct flights. If not possible, allow enough time to transfer between two connecting flights. In this case, a wheelchair special assistance is recommended.  • When booking a flight, seats at the aisle and next to the caregiver should be booked and secured in advance.  • Consider a seat reservation close to the lavatories  • Check and book in advance a special meal request adapted to the passenger’s diet At the airports  • Book an assistance at the arriving and departing airports. Airline and airport specific procedures should be checked and followed.  • If possible, allow plenty of time before departure and book a lounge access if available/possible  • Before boarding, appropriate emptying of the bladder will prevent urinary retention or bladder overflow incontinence when the seatbelt sign is on. In patients with known incontinence, urinary pads should be changed before the flight and appropriate changing material organised. In the plane  • Informing the cabin crew about the condition of the patient may help to raise awareness and avoid unnecessary misunderstandings.  • During the flight, appropriate hydration should be ensured. Alcohol consumption should be avoided as this may alter the cognitive function and may trigger anxious states, disinhibition and delirium.  • Excessive consumption of caffeine or tea should be avoided as these may have diuretic effects  • As gastric emptying is reduced during flight, it is better to take small quantities multiple times during the flight. Food rich in fibres should be avoided.  • Ear plugs or eyes shades may be used during the flight  • We recommend accompanying the patient to the lavatories and provide assistance where needed. Open in new tab Table 2 Non-pharmacological recommendations for travellers with cognitive impairment At home  • Check latest states, airlines and airports regulations in case of infectious disease outbreaks (like COVID-19)  • Visit the airlines’ and airport’s website on special assistance (e.g. wheelchair)  • Consider requesting early boarding  • Book a flight time in the late morning or early afternoon in order not to interfere too much with the daily routine  • Whenever possible, book direct flights. If not possible, allow enough time to transfer between two connecting flights. In this case, a wheelchair special assistance is recommended.  • When booking a flight, seats at the aisle and next to the caregiver should be booked and secured in advance.  • Consider a seat reservation close to the lavatories  • Check and book in advance a special meal request adapted to the passenger’s diet At the airports  • Book an assistance at the arriving and departing airports. Airline and airport specific procedures should be checked and followed.  • If possible, allow plenty of time before departure and book a lounge access if available/possible  • Before boarding, appropriate emptying of the bladder will prevent urinary retention or bladder overflow incontinence when the seatbelt sign is on. In patients with known incontinence, urinary pads should be changed before the flight and appropriate changing material organised. In the plane  • Informing the cabin crew about the condition of the patient may help to raise awareness and avoid unnecessary misunderstandings.  • During the flight, appropriate hydration should be ensured. Alcohol consumption should be avoided as this may alter the cognitive function and may trigger anxious states, disinhibition and delirium.  • Excessive consumption of caffeine or tea should be avoided as these may have diuretic effects  • As gastric emptying is reduced during flight, it is better to take small quantities multiple times during the flight. Food rich in fibres should be avoided.  • Ear plugs or eyes shades may be used during the flight  • We recommend accompanying the patient to the lavatories and provide assistance where needed. At home  • Check latest states, airlines and airports regulations in case of infectious disease outbreaks (like COVID-19)  • Visit the airlines’ and airport’s website on special assistance (e.g. wheelchair)  • Consider requesting early boarding  • Book a flight time in the late morning or early afternoon in order not to interfere too much with the daily routine  • Whenever possible, book direct flights. If not possible, allow enough time to transfer between two connecting flights. In this case, a wheelchair special assistance is recommended.  • When booking a flight, seats at the aisle and next to the caregiver should be booked and secured in advance.  • Consider a seat reservation close to the lavatories  • Check and book in advance a special meal request adapted to the passenger’s diet At the airports  • Book an assistance at the arriving and departing airports. Airline and airport specific procedures should be checked and followed.  • If possible, allow plenty of time before departure and book a lounge access if available/possible  • Before boarding, appropriate emptying of the bladder will prevent urinary retention or bladder overflow incontinence when the seatbelt sign is on. In patients with known incontinence, urinary pads should be changed before the flight and appropriate changing material organised. In the plane  • Informing the cabin crew about the condition of the patient may help to raise awareness and avoid unnecessary misunderstandings.  • During the flight, appropriate hydration should be ensured. Alcohol consumption should be avoided as this may alter the cognitive function and may trigger anxious states, disinhibition and delirium.  • Excessive consumption of caffeine or tea should be avoided as these may have diuretic effects  • As gastric emptying is reduced during flight, it is better to take small quantities multiple times during the flight. Food rich in fibres should be avoided.  • Ear plugs or eyes shades may be used during the flight  • We recommend accompanying the patient to the lavatories and provide assistance where needed. Open in new tab Pharmacological interventions Environmental and physiological changes associated with flying may precipitate acute behavioural disturbances in patients with various stages of cognitive impairment. Behavioural and psychological symptoms of dementia (BPSD) are common and can range from anxiety to psychotic symptoms and depression. In a large longitudinal study following patients with MCI to dementia, 80% of the patients suffered from BPSD.76 When admitted in an acute hospital setting, aggression and agitation were the most frequently reported BPSD in patients with dementia.77 Although no official number is available, the changes in environment while travelling may have similar consequences. Before clearing a patient for travel, it is essential to obtain a medical history of the patient particularly regarding the diagnosis of dementia as BPSD may vary according to the type of dementia and may require different drug treatment.78 Also, a past history of agitation and aggression in a similar setting (i.e. change in environment, hospitalisation) can give a precious insight into possible risk during the flight. Medication for acute episodes of confusional state In-flight acute behavioural disorder may be compared to delirium during hospitalisation. Likewise, non-pharmacological approaches should be used in order to provide reassurance. Precipitating factors, such as hypoglycaemia, pain or constipation should be excluded. Physical constraint should be used with extreme caution. According to IATA recommendations, emergency medical kits on board of commercial aircraft should contain antipsychotic (injection or oral) as well as sedative medications (injection).79 Nonetheless, administration of these emergency drugs should be seen as a last attempt. Instead, it is recommended that the treating physician, after assessing the risk of acute behavioural episodes, provides accompanying caregivers with an emergency medication; this should be administered preventively as soon as first mild symptoms appear to preclude the occurrence of severe symptoms. Ideally, this medication is already part of a pro re nata (PRN) treatment prescribed at home (such as antipsychotics or benzodiazepines). If newly prescribed, a trial before travel is recommended to exclude relevant side effects and familiarise the accompanying caregiver with the response. Although caregivers are frequently involved in medication management of patients with cognitive impairment, appropriate information and education on the administration of these drugs is recommended before the flight.80,81 Lorazepam, a benzodiazepine of short half-life duration, can be used in patients with acute agitation and anxiety. Lorazepam reaches its peak concentration in the blood 60 minutes after sublingual administration. Compared to other benzodiazepines, lorazepam is not metabolized through the cytochrome P450 enzymes in the liver and is therefore safe to use in patients with hepatic or renal conditions.82 Evidence regarding the administration of antipsychotics before flying in patients in dementia is lacking. However, antipsychotics are often prescribed as PRN drugs in hospitalised patients with cognitive impairment at increased risk for delirium.83 Therefore, antipsychotics may be an alternative to benzodiazepines in patients showing a good response to antipsychotics at home or during previous hospitalisations. Although the evidence appears limited, atypical antipsychotic drugs like quetiapine might be favourable in older adults for the treatment of delirium compared to haloperidol or risperidone due to a lower risk for motor side effects.83 The use of melatonin in the prevention and treatment of delirium as well as jet lag has been increasingly described in the recent literature.84,85 Evidence regarding its role in preventing acute confusional states in-flight or post-flight is lacking. Administration of routine medication Experimental studies suggest that circadian rhythm influences different phases of drug metabolism. As a consequence, some drugs, such as cyclosporin or statins, are recommended to be taken at a specific time of the day.86 Interestingly, in 66 patients with schizophrenia treated with antipsychotics, increased QT prolongation was reported during the night.87 One could hypothesise that a change in the internal circadian system occurring during the crossing of time zones may lead to a similar change. So far, no study has investigated the effect of jet lag on drug metabolism. In contrast to hypoglycaemic agents and insulin regimen, there are currently no state-of-the-art recommendations regarding drugs used in dementia in the context of flying.88 The pharmacology of drug treatment used in ad differs from one compound to the other and serum half-life can range from 2 to 80 hours.89 In long-haul flights, we recommend adapting the timing of medication to the local time at arrival. For instance, transatlantic eastward travels often occur during the night and land in the early morning in Europe. In order to allow passengers a smooth transition to the new time zone, airline companies often provide a dinner shortly after take-off and dim the cabin lights shortly after to allow passengers to sleep. Here, we would recommend taking the drugs shortly before dinner and then at arrival of the plane or at home. The role of airline medical services As the cabin environment can pose a significant challenge for passengers travelling with medical issues, advising these patients as a general practitioner can be difficult. In these cases, the airline’s medical department provides support and guidance concerning the decision on fitness to fly and necessary assistance to guarantee a good travelling experience. According to the IATA medical manual, medical clearance by the airline’s medical department generally must be requested if: (1) the passenger suffers from a contagious disease, (2) is likely to be a hazard or discomfort to other passengers because of the physical or behavioural condition, (3) is considered to be a potential risk to the safety on the flight, (4) is incapable of caring for himself and requires special assistance, (5) has a medical condition, which may be adversely affected by the flight environment.90 In these cases, the Special Assistance Form (SAF) and Medical Information Form (MEDIF) forms need to be submitted to the airline’s medical department for medical clearance.91 For passengers with a stable medical condition a Frequent Traveller’s Medical Card (FREMEC) can be requested to avoid medical clearance for each journey. Discussion In this review, we discussed the effect of an aircraft environment—moderate hypoxia, drop in cabin humidity, gas distension, noise and jet lag—on older patients with cognitive impairment. We identified a wide range of symptoms, which may arise in this vulnerable group of passengers, with delirium and agitation being at the most extreme spectrum of symptoms. In the light of the most recent literature, we suggested non-pharmacological and pharmacological interventions to be applied at different stages of the travel process. While our review highlighted how cognitive impairment should not represent a barrier to fly per se, we emphasized the importance of identifying risk factors for in-flight complications related to cognitive impairment in the context of a pre-travel consultation. Our current review was limited by the paucity of data and studies investigating the effect of in-flight changes in older adults and particularly in passengers with cognitive impairment. As a consequence, we had to extrapolate our findings from studies conducted in healthy younger subjects. Therefore, studies investigating the effect of air travel in older passengers, and particular those with cognitive impairment, are urgently needed to unveil the physiological changes underpinning the symptoms related to air travel in this subpopulation. Furthermore, our recommendations regarding pharmacological and non-pharmacological interventions were based on experience in hospital setting. Future research will need to ascertain the efficacy of these interventions during flight. This review aims at filling a current gap in pre-travel recommendations for older passengers with cognitive impairment and setting the path for a closer collaboration between travel medicine practitioners, primary care providers, geriatricians, airlines’ medical services, caregivers and airports. Author Contributions Drafting of the manuscript was carried out by A.S., A.E, G.F., M.G., H.B.F. Critical revision of the manuscript for important intellectual content was performed by A.S, A.E., G.F., M.G., H.B.F. Images were created by A.S. Funding This work was supported by the University Hospital Zürich Healthy Aging Fellowship and an Imperial College President’s PhD scholarship (to A.S.). Conflict of interest None declared. References 1. International Air Transport Association . Annual Review , 2018. https://www.iata.org/publications/Documents/iata-annual-review-2019.pdf (1 June 2020, date last accessed). 2. Glaesser D , Kester J, Paulose H, Alizadeh A, Valentin B. Global travel patterns: an overview . J Travel Med 2017 ; 24 . doi: 10.1093/jtm/tax007 . Google Scholar OpenURL Placeholder Text WorldCat Crossref 3. Tuite AR , Bhatia D, Moineddin R, Bogoch II, Watts AG, Khan K. Global trends in air travel: implications for connectivity and resilience to infectious disease threats . J Travel Med 2020 ;27:taaa070. Google Scholar OpenURL Placeholder Text WorldCat 4. International Air Transport Association . Don’t Make A Slow Recovery More Difficult with Quarantine Measures . 2020 . https://www.iata.org/en/pressroom/pr/2020-05-13-03/ (04 July 2020, date last accessed) . 5. Thibeault C , Evans AD. AsMA medical guidelines for air travel: stresses of flight . Aerospace Medicine and Human Performance 2015 ; 86 : 486 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Bosch SJ , Gharaveis A. Flying solo: a review of the literature on wayfinding for older adults experiencing visual or cognitive decline . Appl Ergon 2017 ; 58 : 327 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Mouchtouri VA , Christoforidou EP, An der Heiden M et al. Exit and entry screening practices for infectious diseases among Travelers at points of entry: looking for evidence on public health impact . Int J Environ Res Public Health 2019 ; 16 :4638. Google Scholar OpenURL Placeholder Text WorldCat 8. Martin-Gill C , Doyle TJ, Yealy DM. In-flight medical emergencies: a review . JAMA 2018 ; 320 : 2580 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Graf J , Stüben U, Pump S. In-flight medical emergencies . Deutsches Arzteblatt International 2012 ; 109 : 591 – 601 quiz 2 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 10. DeJohn CA , Veronneau SJ, Wolbrink AM, Larcher JG, Smith DW. The Evaluation of In-Flight Medical Care Aboard Selected US Air Carriers: 1996 to 1997: Federal Aviation Administration Oklahoma City OK Civil Aeromedical Inst , Federal Aviation Administration technical report DOT/FAA/AM-0013. Washington DC : Office of Aviation Medicine . 2000 . 11. Matsumoto K , Goebert D. In-flight psychiatric emergencies . Aviat Space Environ Med 2001 ; 72 : 919 – 23 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 12. Lobo A , Launer LJ, Fratiglioni L et al. Prevalence of dementia and major subtypes in Europe: a collaborative study of population-based cohorts. Neurologic diseases in the elderly research group . Neurology 2000 ; 54 : S4 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Albert MS , DeKosky ST, Dickson D et al. The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease . Alzheimers Dement 2011 ; 7 : 270 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Arvanitakis Z , Shah RC, Bennett DA. Diagnosis and Management of Dementia: review . JAMA 2019 ; 322 : 1589 – 99 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Nichols E , Szoeke CEI, Vollset SE. GBD 2016 Dementia Collaborators. Global, regional, and national burden of Alzheimer's disease and other dementias: a systematic analysis for the Global Burden of Disease Study 2016 . The Lancet Neurology 2019 ; 18 : 88 – 106 . Google Scholar Crossref Search ADS PubMed WorldCat 16. Carrega C. Family suing American Airlines for losing dad with Alzheimer’s at LaGuardia, leaving him to wander 3 days in frigid temperatures . 2015 . https://www.nydailynews.com/new-york/exclusive-fam-aa-lost-dad-alzheimer-lga-article-1.2334453 (23 March 2020, date last accessed) . 17. Jouvenal J , Hedgpeth D. Woman, 83, who disappeared from airport Friday evening is found dead . 2013 . https://www.washingtonpost.com/local/woman-83-who-disappeared-from-airport-friday-evening-is-found-dead/2013/05/06/20bfe15c-b66a-11e2-aa9e-a02b765ff0ea_story.html (23 March 2020, date last accessed) . 18. Heathrow Media Centre . Heathrow commits to becoming world’s first dementia friendly airport . 2016 . https://mediacentre.heathrow.com/pressrelease/details/81/Corporate-operational-24/7146 (21 February 2020, date last accessed) . 19. Media Centre London Gatwick . New lanyard launched to assist passengers with hidden disabilities . 2016 . http://www.mediacentre.gatwickairport.com/press-releases/2016/16-05-19-new-lanyard-launched-to-assist-passengers-with-hidden-disabilities.aspx (21 February 2020, date last accessed) . 20. Sensalis G . Virgin Atlantic makes flying with dementia easier . 2020 . https://alzlive.com/spirit/travel/virgin-atlantic-makes-flying-dementia-easier/ (21 February 2020, date last accessed) . 21. Susan G . Fly the dementia-friendly skies of Easyjet . https://alzlive.com/spirit/travel/fly-dementia-friendly-skies-easyjet/ (21 February 2020, date last accessed) . 22. Kain D , Findlater A, Lightfoot D et al. Factors affecting pre-travel health seeking behaviour and adherence to pre-travel health advice: a systematic review . J Travel Med 2019 ; 26 :taz059. Google Scholar OpenURL Placeholder Text WorldCat 23. Ahmedzai S , Balfour-Lynn IM, Bewick T et al. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations . Thorax 2011 ; 66 : i1 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 24. Smith D , Toff W, Joy M et al. Fitness to fly for passengers with cardiovascular disease . Heart 2010 ; 96 : ii1 . Google Scholar Crossref Search ADS PubMed WorldCat 25. McCabe T . 'Doc, can I fly to Australia?' a case report and review of delirium following long-haul flight . BJPsych bulletin 2017 ; 41 : 30 – 2 . Google Scholar Crossref Search ADS PubMed WorldCat 26. Rands G . Post-flight confusion . BJPsych bulletin 2017 ; 41 : 181 . Google Scholar Crossref Search ADS PubMed WorldCat 27. Kelly L , Caplan G. Delirium and long haul travel . Age Ageing 2009 ; 38 : 762 . Google Scholar Crossref Search ADS PubMed WorldCat 28. Silverman D , Gendreau M. Medical issues associated with commercial flights . Lancet (London, England) 2009 ; 373 : 2067 – 77 . Google Scholar Crossref Search ADS PubMed WorldCat 29. Ainslie PN , Shaw AD, Smith KJ et al. Stability of cerebral metabolism and substrate availability in humans during hypoxia and hyperoxia . Clinical Science (London, England: 1979) 2014 ; 126 : 661 – 70 . Google Scholar Crossref Search ADS PubMed WorldCat 30. Hochachka PW , Clark CM, Matheson GO et al. Effects on regional brain metabolism of high-altitude hypoxia: a study of six US marines . American Journal of Physiology-Regulatory, Integrative and Comparative Physiology 1999 ; 277 : R314 – 9 . Google Scholar Crossref Search ADS WorldCat 31. Lawley JS , Macdonald JH, Oliver SJ, Mullins PG. Unexpected reductions in regional cerebral perfusion during prolonged hypoxia . J Physiol 2017 ; 595 : 935 – 47 . Google Scholar Crossref Search ADS PubMed WorldCat 32. Leijenaar JF , van Maurik IS, Kuijer JPA et al. Lower cerebral blood flow in subjects with Alzheimer's dementia, mild cognitive impairment, and subjective cognitive decline using two-dimensional phase-contrast magnetic resonance imaging . Alzheimer's & Dementia (Amsterdam, Netherlands) 2017 ; 9 : 76 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat 33. Roher AE , Debbins JP, Malek-Ahmadi M et al. Cerebral blood flow in Alzheimer's disease . Vasc Health Risk Manag 2012 ; 8 : 599 – 611 . Google Scholar Crossref Search ADS PubMed WorldCat 34. Schuff N , Matsumoto S, Kmiecik J et al. Cerebral blood flow in ischemic vascular dementia and Alzheimer's disease, measured by arterial spin-labeling magnetic resonance imaging . Alzheimers Dement 2009 ; 5 : 454 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 35. West JB . The original presentation of Boyle’s law . J Appl Physiol 1999 ; 87 : 1543 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 36. Hinninghofen H , Enck P. Passenger well-being in airplanes . Auton Neurosci 2006 ; 129 : 80 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 37. Allan LM . Diagnosis and Management of Autonomic Dysfunction in dementia syndromes . Curr Treat Options Neurol 2019 ; 21 : 38 . Google Scholar Crossref Search ADS PubMed WorldCat 38. Waseem S , Moshiree B, Draganov PV. Gastroparesis: current diagnostic challenges and management considerations . World J Gastroenterol 2009 ; 15 : 25 – 37 . Google Scholar Crossref Search ADS PubMed WorldCat 39. Reber E , Gomes F, Dähn IA, Vasiloglou MF, Stanga Z. Management of Dehydration in patients suffering swallowing difficulties . J Clin Med 2019 ; 8 :1923. Google Scholar OpenURL Placeholder Text WorldCat 40. Andreas S , Christian K, Angela E. Eng und Laut - der medizinische Notfall im Flugzeug . Der Informierte Arzt 2017 ; 27 – 9 . Google Scholar OpenURL Placeholder Text WorldCat 41. Sampson EL , White N, Lord K et al. Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: a longitudinal cohort study . Pain 2015 ; 156 : 675 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat 42. Chang CC , Lin YF, Chiu CH et al. Prevalence and factors associated with food intake difficulties among residents with dementia . PLoS One 2017 ; 12 : e0171770 . Google Scholar Crossref Search ADS PubMed WorldCat 43. Park MS , Lee HY, Kang HM, Ryu EW, Lee SK, Yeo SG. Clinical manifestations of aural fullness . Yonsei Med J 2012 ; 53 : 985 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 44. DeHart RL . Health issues of air travel . Annu Rev Public Health 2003 ; 24 : 133 – 51 . Google Scholar Crossref Search ADS PubMed WorldCat 45. Bagshaw M , Illig P. The aircraft cabin environment . In: Keystone JS, Kozarsky PE, Connor BA, Nothdurft HD, Mendelson M, Leder K eds. Travel Medicine (Fourth Edition). London : Elsevier , 429 – 38 . OpenURL Placeholder Text WorldCat 46. Nagda NL , Hodgson M. Low relative humidity and aircraft cabin air quality . Indoor Air 2001 ; 11 : 200 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 47. Lindseth PD , Lindseth GN, Petros TV, Jensen WC, Caspers J. Effects of hydration on cognitive function of pilots . Mil Med 2013 ; 178 : 792 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 48. Fong TG , Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment . Nat Rev Neurol 2009 ; 5 : 210 – 20 . Google Scholar Crossref Search ADS PubMed WorldCat 49. Porock D , Clissett P, Harwood RH, Gladman JR. Disruption, control and coping: responses of and to the person with dementia in hospital . Ageing and Society 2015 ; 35 : 37 – 63 . Google Scholar Crossref Search ADS PubMed WorldCat 50. Clark GI , Rock AJ. Processes contributing to the maintenance of flying phobia: a narrative review . Front Psychol 2016 ; 7 : 754 . Google Scholar Crossref Search ADS PubMed WorldCat 51. Zevitas CD , Spengler JD, Jones B et al. Assessment of noise in the airplane cabin environment . J Expo Sci Environ Epidemiol 2018 ; 28 : 568 – 78 . Google Scholar Crossref Search ADS PubMed WorldCat 52. van de Pol I , van Iterson M, Maaskant J. Effect of nocturnal sound reduction on the incidence of delirium in intensive care unit patients: An interrupted time series analysis . Intensive Crit Care Nurs 2017 ; 41 : 18 – 25 . Google Scholar Crossref Search ADS PubMed WorldCat 53. Rains J , Chee N. The role of occupational and physiotherapy in multi-modal approach to tackling delirium in the intensive care . Journal of the Intensive Care Society 2017 ; 18 : 318 – 22 . Google Scholar Crossref Search ADS PubMed WorldCat 54. Hu RF , Jiang XY, Chen J et al. Non-pharmacological interventions for sleep promotion in the intensive care unit . Cochrane Database Syst Rev 2015 ; 2015 : Cd008808 . Google Scholar OpenURL Placeholder Text WorldCat 55. Litton E , Carnegie V, Elliott R, Webb SA. The efficacy of earplugs as a sleep hygiene strategy for reducing delirium in the ICU: a systematic review and meta-analysis . Crit Care Med 2016 ; 44 : 992 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 56. Bin YS , Postnova S, Cistulli PA. What works for jetlag? A systematic review of non-pharmacological interventions . Sleep Med Rev 2019 ; 43 : 47 – 59 . Google Scholar Crossref Search ADS PubMed WorldCat 57. Eastman CI , Burgess HJ. How to travel the world without jet lag . Sleep Med Clin 2009 ; 4 : 241 – 55 . Google Scholar Crossref Search ADS PubMed WorldCat 58. Stutz A , Ensslin A. CME: jet lag jetlag . Praxis 2018 ; 107 : 805 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 59. Musiek ES . Circadian clock disruption in neurodegenerative diseases: cause and effect? Front Pharmacol 2015 ; 6 : 29 . Google Scholar Crossref Search ADS PubMed WorldCat 60. Musiek ES , Xiong DD, Holtzman DM. Sleep, circadian rhythms, and the pathogenesis of Alzheimer disease . Exp Mol Med 2015 ; 47 : e148 . Google Scholar Crossref Search ADS PubMed WorldCat 61. Tranah GJ , Blackwell T, Stone KL et al. Circadian activity rhythms and risk of incident dementia and mild cognitive impairment in older women . Ann Neurol 2011 ; 70 : 722 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 62. Wu Y-H , Swaab DF. Disturbance and strategies for reactivation of the circadian rhythm system in aging and Alzheimer’s disease . Sleep Med 2007 ; 8 : 623 – 36 . Google Scholar Crossref Search ADS PubMed WorldCat 63. Innes A , Page SJ, Cutler C. Barriers to leisure participation for people with dementia and their carers: An exploratory analysis of carer and people with dementia’s experiences . Dementia 2015 ; 15 : 1643 – 65 . Google Scholar Crossref Search ADS PubMed WorldCat 64. Office of the Federal Register . Code of Federal Regulations, Title 14, Aeronautics and Space, PT. 200–1199, Revised as of January 1, 2010, Subpart H - Section § 382.111 . Washington DC: U.S. Government Printing Office , 2010 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 65. Regulation (EC) No 1107/2006 of the European Parliament and of the Council of 5 July 2006 Concerning the Rights of Disabled Persons and Persons with Reduced Mobility When Travelling by Air . 2006 . https://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX%3A32006R1107 (29 May 2020, date last accessed) . 66. Gautret P , Gaudart J, Leder K et al. Travel-associated illness in older adults (> 60 y) . J Travel Med 2012 ; 19 : 169 – 77 . Google Scholar Crossref Search ADS PubMed WorldCat 67. Keyes LE , Mather L, Duke C et al. Older age, chronic medical conditions and polypharmacy in Himalayan trekkers in Nepal: an epidemiologic survey and case series . J Travel Med 2016 ; 23 :taw052. Google Scholar OpenURL Placeholder Text WorldCat 68. Oldenburg M , Herzog J, Püschel K, Harth V. Mortality of German travellers on passenger vessels . J Travel Med 2016 ; 23 :tav003. Google Scholar OpenURL Placeholder Text WorldCat 69. Darrat M , Flaherty GT. Retrospective analysis of older travellers attending a specialist travel health clinic . Trop Dis Travel Med Vaccines 2019 ; 5 : 17 . Google Scholar Crossref Search ADS PubMed WorldCat 70. Lee TK , Hutter JN, Masel J, Joya C, Whitman TJ. Guidelines for the prevention of travel-associated illness in older adults . Tropical Diseases, Travel Medicine and Vaccines 2017 ; 3 : 10 . Google Scholar Crossref Search ADS PubMed WorldCat 71. Alzheimer’s Association . Traveling . https://www.alz.org/help-support/caregiving/safety/traveling (06 March 2020, date last accessed) . 72. Oakes M , Bor R. The psychology of fear of flying (part II): a critical evaluation of current perspectives on approaches to treatment . Travel Med Infect Dis 2010 ; 8 : 339 – 63 . Google Scholar Crossref Search ADS PubMed WorldCat 73. Hshieh TT , Yang T, Gartaganis SL, Yue J, Inouye SK. Hospital elder life program: systematic review and meta-analysis of effectiveness . The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry 2018 ; 26 : 1015 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 74. Inouye SK , Zhang Y, Jones RN, Kiely DK, Yang F, Marcantonio ER. Risk factors for delirium at discharge: development and validation of a predictive model . Arch Intern Med 2007 ; 167 : 1406 – 13 . Google Scholar Crossref Search ADS PubMed WorldCat 75. Meagher DJ . Delirium: optimising management . BMJ (Clinical Research Ed) 2001 ; 322 : 144 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 76. Lyketsos CG , Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study . JAMA 2002 ; 288 : 1475 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat 77. White N , Leurent B, Lord K, Scott S, Jones L, Sampson EL. The management of behavioural and psychological symptoms of dementia in the acute general medical hospital: a longitudinal cohort study . Int J Geriatr Psychiatry 2017 ; 32 : 297 – 305 . Google Scholar Crossref Search ADS PubMed WorldCat 78. Chiu M-J , Chen T-F, Yip P-K, Hua M-S, Tang L-Y. Behavioral and Psychologic symptoms in different types of dementia . J Formos Med Assoc 2006 ; 105 : 556 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 79. Sand M , Gambichler T, Sand D, Thrandorf C, Altmeyer P, Bechara FG. Emergency medical kits on board commercial aircraft: a comparative study . Travel Med Infect Dis 2010 ; 8 : 388 – 94 . Google Scholar Crossref Search ADS PubMed WorldCat 80. Manias E , Bucknall T, Hughes C, Jorm C, Woodward-Kron R. Family involvement in managing medications of older patients across transitions of care: a systematic review . BMC Geriatr 2019 ; 19 : 95 . Google Scholar Crossref Search ADS PubMed WorldCat 81. Travis SS , Bethea LS, Winn P. Medication administration hassles reported by family caregivers of dependent elderly persons . The Journals of Gerontology: Series A 2000 ; 55 : M412 – 7 . Google Scholar Crossref Search ADS WorldCat 82. Griffin CE , 3rd, Kaye AM, Bueno FR, Kaye AD. Benzodiazepine pharmacology and central nervous system-mediated effects . Ochsner J 2013 ; 13 : 214 – 23 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 83. Riviere J , van der Mast RC, Vandenberghe J, Van Den Eede F. Efficacy and tolerability of atypical antipsychotics in the treatment of delirium: a systematic review of the literature . Psychosomatics 2019 ; 60 : 18 – 26 . Google Scholar Crossref Search ADS PubMed WorldCat 84. Choy SW , Yeoh AC, Lee ZZ, Srikanth V, Moran C. Melatonin and the prevention and Management of Delirium: a scoping study . Front Med 2017 ; 4 : 242 . Google Scholar Crossref Search ADS WorldCat 85. Srinivasan V , Spence DW, Pandi-Perumal SR, Trakht I, Cardinali DP. Jet lag: therapeutic use of melatonin and possible application of melatonin analogs . Travel Med Infect Dis 2008 ; 6 : 17 – 28 . Google Scholar Crossref Search ADS PubMed WorldCat 86. Baraldo M . The influence of circadian rhythms on the kinetics of drugs in humans . Expert Opin Drug Metab Toxicol 2008 ; 4 : 175 – 92 . Google Scholar Crossref Search ADS PubMed WorldCat 87. Watanabe J , Suzuki Y, Fukui N et al. Increased risk of antipsychotic-related QT prolongation during nighttime: a 24-hour holter electrocardiogram recording study . J Clin Psychopharmacol 2012 ; 32 : 18 – 22 . Google Scholar Crossref Search ADS PubMed WorldCat 88. Chandran M , Edelman SV. Have insulin, will fly: diabetes management during air travel and time zone adjustment strategies . Clinical Diabetes 2003 ; 21 : 82 . Google Scholar Crossref Search ADS WorldCat 89. Cummings JL . Alzheimer's disease . N Engl J Med 2004 ; 351 : 56 – 67 . Google Scholar Crossref Search ADS PubMed WorldCat 90. International Air Transport Association . Medical Manual , Montreal-Geneva : International Air Transport Association . 2018 . 91. Stutz A , Ensslin A. Hausärztliche Probleme rund um Flugreisen . Praxis 2016 ; 105 : 821 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat © International Society of Travel Medicine 2020. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Are patients with cognitive impairment fit to fly? Current evidence and practical recommendations
JF - Journal of Travel Medicine
DO - 10.1093/jtm/taaa123
DA - 2021-01-06
UR - https://www.deepdyve.com/lp/oxford-university-press/are-patients-with-cognitive-impairment-fit-to-fly-current-evidence-and-SjrDZsaH0r
VL - 28
IS - 1
DP - DeepDyve
ER -