International Travel in the Elderly: Observations from the “Chutzpah Mission”

Early in 2004, I was asked to accompany a group of 10 nursing home residents on an experimental 6000-mile journey. This historic mission would prove to be a fascinating and most favorable experience for me, one that I would really like to share. At the time, the Executive Vice-President of the Hebrew Home for the Aged at Riverdale had approached me with this novel itinerary for the “Chutzpah Mission,” a plan to send ten elderly nursing home residents on an 8-day tour of the land of Israel. My first impulse was to go to my computer and search the medical literature for more information and possible recommendations regarding overseas travel for the elderly population. To my surprise, I found relatively little written on this subject. Needless to say, I had my reservations about taking a group of nursing home seniors in their 80s and 90s on such a long and arduous trip.

Chutzpah is a Yiddish word, which has by now worked its way into the American vernacular. Loosely translated, it is a noun that means “nerve” or “audacity.” After all, it certainly takes courage for octo- and nonagenarians to embark on a 6000-mile transatlantic journey.

What was their motivation to leave the comfort and security of the nursing home environment for an uncertain and unpredictable trip to Israel? For some, it was the opportunity to rekindle the adventurous spirit of their youth; for others, it was the chance to fulfill a lifelong dream of visiting the Holy Land, a dream that ordinarily would never have been realized at such an advanced age. After all, elderly and infirm nursing home residents don’t normally take to the skies and cross the Atlantic.

How do the elderly handle the change in cabin pressure at an altitude of 35,000 feet? How can deep venous thrombosis be prevented in this situation? What about issues with jet lag? When should the daily medications be administered after the time zone changes? What other unknown issues will arise during the trip that I cannot foresee?

Participation in this unique travel opportunity was entirely voluntary. In fact, when the itinerary for this historic trip was unveiled, the response was overwhelming. In order to limit the group size and select those seniors who were most physically fit to undertake this journey, several guidelines were established and adhered to. Participants had to be capable of ambulating at least 15 feet with or without an assistive device. A diagnosis of dysphagia requiring altered-consistency solid foods or thickened liquids was an absolute contraindication to participation. Individuals who were oxygen-dependent were also excluded. The eclectic group of ten seniors carried a variety of diagnoses with them. The most common diagnoses were congestive heart failure, hypertension, and coronary artery disease. One resident had suffered a stroke 6 months earlier. Another resident had a stasis ulcer on her leg that required twice-daily dressing changes.

The group of ten seniors was accompanied by our team of nine nursing home staff members. The team was composed of a board-certified geriatrician (myself), two registered nurses, two certified nurses’ aides, two social workers, and two additional chaperones. Advanced arrangements were in place with a local medical center in Jerusalem, should the need arise. In addition, durable medical equipment, including wheelchairs, portable oxygen, and a nebulizer, were obtained in advance and would be kept on hand. The team met numerous times before the trip to plan and discuss all possible scenarios that could arise in order to be prepared for any contingency.

I, as the trip doctor, carried all the medical records for each participant. The RNs were charged with the responsibility of toting the medications bag along on the entire tour. In addition to all the routine medications, we brought what I felt were the most likely anticipated as-needed medications, including acetaminophen, aspirin, antacids, antidiarrheals, laxatives, albuterol, sublingual nitroglycerin, scopolamine patches, trimethobenzamide suppositories, zolpidem, diphenhydramine, and injectable epinephrine. Administration of routine medications involved scrupulous time-keeping, particularly during the in-flight periods. In most cases, the medication administration times were adjusted by 3.5 hours per day over a 2-day window during the travel periods to accommodate for a 7-hour time zone difference. This method provided for a very smooth transition to the new time zone.

Another important issue that needed to be addressed was the prophylaxis of deep venous thrombosis during the 10-hour flight. Four of the ten residents were already anticoagulated on warfarin for pre-existing medical conditions (three for atrial fibrillation, one for a cardiovascular accident). The international normalized ratio values were checked and confirmed to be within therapeutic range (2.0-3.0) prior to departure. The remaining residents were given T.E.D. Stockings to wear for the duration of the flight and were offered a baby aspirin (if not already on aspirin therapy, and if not contraindicated). In addition, attempts were made to ambulate all the residents at least twice during the flight. Throughout the course of the trip and in the 3-month period following, no thromboembolic events developed in any of the residents.

Once we arrived in Israel, the next challenge we faced related to diet. Nursing home residents are primarily creatures of habit, fixed within a relatively narrow menu of daily meal choices. Faced with the exotic, often spicy selection of Middle Eastern cuisine, one could certainly wonder how the nursing home resident would react. My own hesitations and concerns were soon dispelled when I observed a most unexpected phenomenon. On day 1, most of the residents sought the more familiar, bland food choices from the menu. This would soon change, however. By day 2, the residents began choosing the more pungent, zesty Israeli foods from the menu. Without exception, it was clear that the residents were really enjoying their new food choices. The more traditional bread with butter was soon replaced by pita with hummus spread. All the staff members observed that appetites had improved significantly. In the 1-month period following the Chutzpah Mission, I reviewed the weights of all the trip participants. Not surprisingly, the residents had gained an average of 1.5 lbs (range, 0.8-2.1 lbs), compared with their pre-trip weight.

Sightseeing at ancient sites throughout Israel was truly the ultimate geriatric adventure. Although we traveled primarily by bus, we took along with us sufficient wheelchairs to accommodate each resident. Nevertheless, many of the seniors adamantly refused to be dependent on being wheeled, and insisted on ambulating with their rolling walkers on the limited sections of the tour that involved navigating on footpaths. This, of course, was no easy accomplishment, and considerably more rigorous than one could ever anticipate. Most of the maze-like streets and walkways in the Old City in Jerusalem are paved with uneven cobblestones. One can only imagine the challenges these valiant seniors faced in navigating their rolling walkers along such bumpy, uneven terrain. It was particularly inspiring to observe many of these elderly travelers exert their independence by refusing wheelchairs and maneuvering their walkers along the ancient footpaths atop Masada in the Judean Desert, and along the shores of the Dead Sea.

International travel in the over-80 population has not previously been documented in the medical literature. The Chutzpah Mission was the first-ever nursing home trip of its kind. In the time that has passed since my return, I have had the opportunity to meet with many of the participants and discuss their feelings and experiences. Without hesitation, they express fond nostalgia at having undertaken the trip, and report feelings of overall well-being. As I reflect upon my week-long adventure with the Chutzpah Mission, I feel a strong sense of respect and awe for this brave group of seniors who chose to undertake this difficult endeavor, and I realize how even in old age, nothing is impossible.