Evidence-map supplement for IAG Medical Forum presentation. Last updated 21 April 2026.

Purpose. This appendix converts the presentation slides into a structured evidence-search map. Each question is designed to retrieve systematic review, meta-analysis, guideline or high-quality review evidence that can support best practice in older-person commercial medical escort and repatriation decisions. Important interpretation. The traffic-light colour is an evidence-quality and directness rating, not a clinical importance rating. Red topics may be highly important; they simply have sparse direct evidence and are strong candidates for service audit, case-series review or prospective research.

Traffic-light coding

Green – stronger evidence Systematic reviews, meta-analyses or mature guidelines directly support the principle.

Amber – indirect/mixed evidence Good evidence exists but is adjacent, condition-specific or not directly about commercial repatriation.

Red – sparse direct evidence Evidence is mainly expert consensus, case series, grey literature or extrapolation.

Evidence-map summary

No.	Slide topic	Rating	Primary evidence gap
1	Opening case: fitness-to-fly versus fitness-to-travel	Amber	Indirect but useful evidence; direct repatriation evidence remains limited.
2	Normal ageing, frailty, dementia and delirium	Green	Guideline and diagnostic review evidence is strong, though not travel-specific.
3	Dementia plus acute insult: delirium until proven otherwise	Green	High-quality delirium prevention and guideline evidence supports best practice; travel evidence is indirect.
4	Commercial flight as a low-grade physiological stress test	Amber	Flight physiology guidance is established, but geriatric-specific outcome evidence is limited.
5	Cardiopulmonary reserve: 50 m walk, 6-minute walk, HAST	Amber	Useful guideline-supported assessment tools; prediction is imperfect and often disease-specific.
6	Chronic conditions consuming reserve: COPD, CAD, CHF, anaemia, renal disease, diabetes	Amber	Good condition-specific guidance; limited integrated evidence for multimorbid older travellers.
7	The door-to-door burden of travel	Red	Direct systematic evidence for airport-process risk in frail/dementia travellers is sparse.
8	Circadian disruption and medication timing across time zones	Amber	Travel medicine guidance is strong; systematic evidence for older polypharmacy is limited.
9	Non-medical escort as risk mitigation	Red	Common-sense and consensus-rich, but direct comparative outcome evidence is weak.
10	Hospital-associated deconditioning: physical and cognitive	Green	Systematic review and geriatric literature strongly support this as a key risk domain.
11	Why 7 days after discharge is not equivalent at 40 and 85	Amber	Strong geriatric recovery evidence; limited procedure-specific travel evidence.
12	Financial burden: delay versus early escorted repatriation	Red	Sparse direct health-economic evidence; high value as a research/audit topic.
13	ICU recovery and post-intensive-care cognitive impairment	Green	Systematic review/meta-analysis evidence supports major cognitive and functional risk after ICU.
14	Dementia traveller fit-to-fly trigger points	Amber	Reasonable consensus and adjacent evidence; direct air travel outcome prediction remains thin.
15	Why dementia travellers fail the mission	Amber	Good adjacent evidence on BPSD, delirium triggers and dementia transitions; travel-specific outcomes are emerging.
16	Dementia travel planning bundle	Amber	Multicomponent delirium prevention is well supported; the travel-bundle application is indirect.
17	Behavioural disturbance: the first-line drug is not a drug	Green	Guidelines and umbrella-review evidence support non-pharmacological first-line management.
18	Chemical restraint during movement and flight	Amber	Good cautionary guidance and harm evidence; transport-specific comparative evidence is limited.
19	Palliative / last-goodbye travellers	Red	High human importance but sparse systematic evidence; case series, guidance and ethics literature dominate.
20	Closing framework: the 6 Cs	Amber	Strong geriatric assessment evidence; proposed travel framework requires validation.

How to use the search strings

For PubMed, add AND systematic[sb] to high-recall searches when seeking systematic reviews. For Ovid MEDLINE or Embase, translate concepts into MeSH/Emtree and add a systematic review/guideline hedge. Cochrane recommends searching multiple sources because MEDLINE alone is not adequate for systematic reviews.

Slide-by-slide research questions and search strategies

1. Opening case: fitness-to-fly versus fitness-to-travel

Evidence rating	Amber – Indirect but useful evidence; direct repatriation evidence remains limited.
Research-grade question	In older adults requiring medical repatriation or long-distance commercial air travel after acute illness, which multidomain assessment factors best predict adverse travel outcomes compared with diagnosis-based fitness-to-fly clearance alone?
Evidence rating rationale	Expect strong adjacent evidence from comprehensive geriatric assessment, chronic illness travel preparation, and aviation-medicine consensus; expect few controlled studies in commercial repatriation.
Best-practice direction to test	Build the question around reserve, function, cognition, care requirement and contingencies rather than a single diagnosis or a fixed number of days post-discharge.
Suggested databases / sources	PubMed/MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, Trip, aviation medicine journals, grey literature from airline/assistance organisations.

Starter search string:

(older adult* OR geriatric* OR elderly OR frail*) AND (“air travel” OR “commercial flight” OR aviation OR repatriation OR “medical repatriation”) AND (“fitness to fly” OR “fitness to travel” OR “medical clearance” OR “risk assessment”) AND (outcome* OR complication* OR adverse OR mortality OR “failed boarding”) AND systematic[sb]

Anchor references: [3], [25], [15], [7]

2. Normal ageing, frailty, dementia and delirium

Evidence rating	Green – Guideline and diagnostic review evidence is strong, though not travel-specific.
Research-grade question	In older adults undergoing travel or post-acute care transitions, which diagnostic features and validated screening tools best distinguish normal ageing, frailty, dementia and delirium?
Evidence rating rationale	The evidence base is mature for distinguishing dementia and delirium, and diagnostic accuracy reviews exist for delirium tools such as 4AT. It is less mature for how these screening results should change escort requirements.
Best-practice direction to test	Frame acute change, fluctuation and attention impairment as delirium triggers until proven otherwise. Use the travel assessment to establish baseline cognition and acute deviation.
Suggested databases / sources	PubMed, Cochrane Library, NICE, PsycINFO, CINAHL, AGS/BGS guidance, Australian dementia and delirium guidance.

Starter search string:

(“older adult*” OR geriatric* OR elderly) AND (dementia OR “cognitive impairment” OR frailty OR delirium) AND (“differential diagnosis” OR screening OR assessment OR “diagnostic accuracy” OR CAM OR 4AT) AND (systematic review OR meta-analysis OR guideline)

Anchor references: [4], [5], [6], [17]

3. Dementia plus acute insult: delirium until proven otherwise

Evidence rating	Green – High-quality delirium prevention and guideline evidence supports best practice; travel evidence is indirect.
Research-grade question	In older adults with pre-existing dementia, which strategies best detect and prevent delirium during hospital discharge, care transfer and exposure to unfamiliar environments?
Evidence rating rationale	Multicomponent non-pharmacological delirium prevention evidence is strong for hospitalised older adults; travel and airport environments need extrapolation.
Best-practice direction to test	Look first for reversible precipitants: infection, hypoxia, pain, urinary retention, constipation, dehydration, sleep loss, opioid or anticholinergic burden.
Suggested databases / sources	PubMed, Cochrane Library, Embase, CINAHL, PsycINFO, NICE evidence reviews, Joanna Briggs Institute.

Starter search string:

(dementia OR “cognitive impairment”) AND (delirium OR “acute confusion”) AND (“transition of care” OR discharge OR hospitalisation OR hospitalization OR “unfamiliar environment” OR travel OR transfer) AND (prevention OR detection OR screening OR management) AND systematic[sb]

Anchor references: [5], [16], [6], [21]

4. Commercial flight as a low-grade physiological stress test

Evidence rating	Amber – Flight physiology guidance is established, but geriatric-specific outcome evidence is limited.
Research-grade question	In older adults or adults with reduced physiological reserve, how does exposure to commercial cabin altitude and hypobaric hypoxia affect cardiopulmonary physiology and adverse clinical outcomes during or after flight?
Evidence rating rationale	Guidelines clearly describe cabin altitude risks for respiratory and cardiovascular disease. The evidence is less direct for frailty and older-person physiological reserve as independent modifiers.
Best-practice direction to test	Treat commercial flight as a stress exposure layered on the door-to-door journey, not a passive seated event.
Suggested databases / sources	PubMed, Embase, Cochrane Library, British Thoracic Society, Aerospace Medical Association, British Cardiovascular Society, IATA/CAA guidance.

Starter search string:

(“commercial flight” OR “air travel” OR aviation OR “cabin altitude” OR “hypobaric hypoxia”) AND (“older adult*” OR elderly OR geriatric* OR frail* OR “reduced physiological reserve”) AND (cardiopulmonary OR cardiovascular OR respiratory OR oxygenation OR hypoxaemia OR hypoxemia) AND (systematic review OR meta-analysis OR guideline)

Anchor references: [3], [10], [11], [7]

5. Cardiopulmonary reserve: 50 m walk, 6-minute walk, HAST

Evidence rating	Amber – Useful guideline-supported assessment tools; prediction is imperfect and often disease-specific.
Research-grade question	In adults with chronic respiratory or cardiovascular disease being assessed for air travel, how accurately do the 50 m walk test, 6-minute walk test and hypoxic challenge test predict inflight hypoxaemia or need for supplemental oxygen?
Evidence rating rationale	HAST and walk tests are commonly referenced, but their predictive value varies by disease group; resting SpO2 alone is insufficient in many chronic respiratory conditions.
Best-practice direction to test	Combine resting observations with exertional tolerance, recovery time, haemoglobin, co-morbidity and the expected airport burden.
Suggested databases / sources	PubMed, Embase, Cochrane Library, respiratory medicine databases, BTS clinical statement, aviation medicine guidance.

Starter search string:

(“air travel” OR “commercial flight” OR “fitness to fly”) AND (“hypoxic challenge test” OR “hypoxia altitude simulation test” OR HAST OR “6 minute walk” OR “six minute walk” OR “50 m walk” OR “walk test”) AND (hypoxaemia OR hypoxemia OR oxygen OR desaturation OR “supplemental oxygen”) AND (systematic review OR meta-analysis OR guideline)

Anchor references: [3], [10], [7]

6. Chronic conditions consuming reserve: COPD, CAD, CHF, anaemia, renal disease, diabetes

Evidence rating	Amber – Good condition-specific guidance; limited integrated evidence for multimorbid older travellers.
Research-grade question	In older adults with chronic cardiopulmonary or metabolic comorbidities, which conditions most increase the risk of adverse events, hypoxaemia, functional failure or medical escort requirement during commercial air travel?
Evidence rating rationale	Disease-specific guidance exists, but few reviews quantify the combined effect of frailty, multimorbidity and flight physiology.
Best-practice direction to test	Search and synthesize by reserve domains: respiratory reserve, cardiac reserve, oxygen carrying capacity, renal/metabolic stability and medication self-management.
Suggested databases / sources	PubMed, Embase, Cochrane Library, BTS, BCS, CDC Yellow Book, diabetes and thrombosis guideline sources.

Starter search string:

(“older adult*” OR elderly OR geriatric* OR frail*) AND (multimorbidity OR comorbid* OR COPD OR “coronary artery disease” OR “heart failure” OR anaemia OR diabetes OR “chronic kidney disease”) AND (“air travel” OR “commercial flight” OR “fitness to fly” OR repatriation) AND (risk OR adverse OR complication* OR hypoxaemia OR “medical escort”) AND systematic[sb]

Anchor references: [10], [11], [9], [7], [30]

7. The door-to-door burden of travel

Evidence rating	Red – Direct systematic evidence for airport-process risk in frail/dementia travellers is sparse.
Research-grade question	In frail or cognitively impaired older adults, how do airport processes, transfers, walking distance, queuing, toileting, sensory overload and layovers contribute to falls, delirium, failed travel or need for escort support?
Evidence rating rationale	Dementia-friendly transport and travel scoping reviews identify barriers and staff/environment needs, but outcome studies are limited.
Best-practice direction to test	Use door-to-door journey mapping as the unit of analysis: home/hospital to airport, landside, airside, boarding, in-flight, layover, arrival and handover.
Suggested databases / sources	PubMed, CINAHL, PsycINFO, Scopus, TRID/transport databases, disability travel literature, airport accessibility grey literature.

Starter search string:

(“older adult*” OR frail* OR dementia OR “cognitive impairment” OR disability) AND (airport OR “air travel” OR “commercial flight” OR layover OR transfer OR “long-distance travel”) AND (falls OR delirium OR fatigue OR toileting OR “activities of daily living” OR assistance OR escort) AND (systematic review OR scoping review OR guideline)

Anchor references: [19], [20], [7]

8. Circadian disruption and medication timing across time zones

Evidence rating	Amber – Travel medicine guidance is strong; systematic evidence for older polypharmacy is limited.
Research-grade question	In older adults with chronic disease crossing multiple time zones, what medication-timing interventions reduce dosing errors, destabilisation of chronic illness, sleep disruption or delirium?
Evidence rating rationale	CDC guidance explicitly highlights medication timing across time zones and hand-luggage carriage. Diabetes air travel has systematic review evidence; broader geriatric polypharmacy travel evidence is thinner.
Best-practice direction to test	Prioritise high-harm regimens: insulin, anticoagulants, Parkinson medications, anticonvulsants, sedatives, opioids, diuretics and antihypertensives.
Suggested databases / sources	PubMed, Embase, Cochrane Library, travel medicine guidelines, pharmacy safety databases, diabetes/endocrine practice literature.

Starter search string:

(“older adult*” OR elderly OR geriatric*) AND (“time zone” OR jet lag OR “circadian disruption” OR “transmeridian travel” OR “international travel”) AND (medication OR polypharmacy OR insulin OR anticoagulant* OR Parkinson* OR anticonvulsant* OR opioid* OR sedative*) AND (“medication error*” OR adherence OR overdose OR underdose OR delirium OR safety) AND systematic[sb]

Anchor references: [7], [8], [30], [31]

9. Non-medical escort as risk mitigation

Evidence rating	Red – Common-sense and consensus-rich, but direct comparative outcome evidence is weak.
Research-grade question	In older or cognitively impaired travellers who are medically stable but functionally vulnerable, does a non-medical escort compared with unescorted travel reduce adverse events, failed travel, medication errors, falls, wandering or care escalation?
Evidence rating rationale	Direct evidence on commercial non-medical escorts is limited. Caregiver support, dementia-friendly transport and transition-of-care evidence provide the closest scaffolding.
Best-practice direction to test	Convert escort decisions into measurable outcomes: hydration, toileting, medication administration, wayfinding, behavioural containment, fall prevention and handover reliability.
Suggested databases / sources	PubMed, Embase, CINAHL, PsycINFO, Scopus, travel assistance literature, care-transition literature.

Starter search string:

(“older adult*” OR geriatric* OR elderly OR dementia OR frail*) AND (“non-medical escort” OR escort OR caregiver OR “travel companion” OR attendant OR assistance) AND (“air travel” OR repatriation OR “medical transport” OR “long-distance travel” OR discharge) AND (falls OR delirium OR medication OR safety OR adverse OR “activities of daily living”) AND (systematic review OR scoping review OR guideline)

Anchor references: [3], [19], [20], [15]

10. Hospital-associated deconditioning: physical and cognitive

Evidence rating	Green – Systematic review and geriatric literature strongly support this as a key risk domain.
Research-grade question	In hospitalised older adults, what is the incidence, rate of onset and reversibility of hospital-associated deconditioning, including physical and cognitive decline, and which interventions reduce functional loss?
Evidence rating rationale	The evidence supports hospital-associated deconditioning as multidimensional and particularly relevant to frail older adults and those with cognitive impairment.
Best-practice direction to test	Do not measure readiness only by pathology stability. Include mobility, ADLs, nutrition, cognition, continence, sleep and recovery trajectory.
Suggested databases / sources	PubMed, Cochrane Library, Embase, CINAHL, Age and Ageing, geriatric medicine journals, rehabilitation databases.

Starter search string:

(“hospital-associated deconditioning” OR “hospital acquired deconditioning” OR “hospital-associated functional decline” OR “hospital acquired functional decline”) AND (“older adult*” OR elderly OR geriatric* OR frail*) AND (physical OR cognitive OR delirium OR mobility OR “activities of daily living”) AND (incidence OR prevention OR rehabilitation OR recovery) AND systematic[sb]

Anchor references: [13], [14], [15], [3]

11. Why 7 days after discharge is not equivalent at 40 and 85

Evidence rating	Amber – Strong geriatric recovery evidence; limited procedure-specific travel evidence.
Research-grade question	After acute hospitalisation for the same medical event, how do age, frailty and baseline functional status modify recovery time, readmission risk and readiness for independent travel or discharge?
Evidence rating rationale	Searches should separate recovery of the disease process from recovery of independent function. Direct evidence for specific commercial flight delay intervals by age is unlikely.
Best-practice direction to test	Replace a fixed-delay rule with a trajectory rule: stable pathology, stable function, stable cognition, stable medications and stable travel logistics.
Suggested databases / sources	PubMed, Embase, Cochrane Library, CINAHL, rehabilitation databases, geriatric discharge planning literature.

Starter search string:

(“older adult*” OR elderly OR geriatric* OR frail*) AND (“hospital discharge” OR “post-discharge” OR “recovery trajectory” OR “functional recovery”) AND (“acute illness” OR surgery OR infection OR “cardiac event” OR pneumonia) AND (readmission OR mortality OR “functional decline” OR “activities of daily living” OR “time to recovery”) AND systematic[sb]

Anchor references: [13], [14], [15], [7]

12. Financial burden: delay versus early escorted repatriation

Evidence rating	Red – Sparse direct health-economic evidence; high value as a research/audit topic.
Research-grade question	For older travellers hospitalised abroad, what is the comparative clinical and economic impact of delayed recovery before travel versus early repatriation with medical or non-medical escort?
Evidence rating rationale	This area will probably need retrospective cohort studies, insurer case-cost datasets, and decision modelling rather than systematic-review-only evidence.
Best-practice direction to test	A useful audit metric would be: extra accommodation/recovery costs versus change in escort level, flight class, air ambulance avoidance, readmission/diversion and patient-centred outcomes.
Suggested databases / sources	PubMed, Embase, EconLit, Scopus, insurance medicine journals, air medical journals, assistance-company grey literature.

Starter search string:

(“older adult*” OR elderly OR geriatric* OR frail*) AND (“medical repatriation” OR “aeromedical evacuation” OR “medical escort” OR “air ambulance” OR “travel insurance”) AND (delay OR “early repatriation” OR “fitness to fly” OR discharge) AND (cost OR “cost effectiveness” OR economic OR outcome* OR readmission OR mortality) AND (systematic review OR scoping review OR guideline OR “economic evaluation”)

Anchor references: [25], [3], [26]

13. ICU recovery and post-intensive-care cognitive impairment

Evidence rating	Green – Systematic review/meta-analysis evidence supports major cognitive and functional risk after ICU.
Research-grade question	In older ICU survivors, what is the prevalence, duration and recovery trajectory of post-intensive care cognitive impairment, and what discharge or transition interventions improve functional and cognitive outcomes?
Evidence rating rationale	Recent proportional meta-analysis reports high short-term cognitive impairment after ICU discharge and persistent longer-term prevalence in many survivors.
Best-practice direction to test	Treat ICU discharge as a cognitive-risk flag. Fitness-to-travel should include attention, orientation, medication comprehension and ability to cooperate with airport/airline processes.
Suggested databases / sources	PubMed, Cochrane Library, Embase, CINAHL, PsycINFO, ICU survivorship literature, critical care guideline sources.

Starter search string:

(“intensive care” OR ICU OR “critical illness”) AND (“older adult*” OR elderly OR geriatric*) AND (“post-intensive care syndrome” OR PICS OR “cognitive impairment” OR delirium OR “functional recovery”) AND (prevalence OR recovery OR rehabilitation OR discharge OR transition) AND systematic[sb]

Anchor references: [18], [5], [16]

14. Dementia traveller fit-to-fly trigger points

Evidence rating	Amber – Reasonable consensus and adjacent evidence; direct air travel outcome prediction remains thin.
Research-grade question	In people with dementia or mild cognitive impairment undertaking commercial air travel, which pre-travel clinical and behavioural criteria best predict safe travel completion without agitation, delirium, refusal, wandering or escalation of care?
Evidence rating rationale	IAG provides practical fit-to-fly criteria; external evidence mainly comes from dementia, delirium, caregiver and transport/accessibility literature.
Best-practice direction to test	Target predictive factors that are auditable: baseline cognition, recent delirium, aggression/agitation, cooperation, locus of control, familiar escort availability, sensory aids and medication stability.
Suggested databases / sources	PubMed, PsycINFO, CINAHL, Cochrane Library, dementia travel/tourism literature, aviation medicine guidance.

Starter search string:

(dementia OR “mild cognitive impairment” OR “cognitive impairment”) AND (“air travel” OR “commercial flight” OR travel OR repatriation OR “medical transport”) AND (agitation OR aggression OR wandering OR delirium OR “behavioural symptoms” OR refusal OR safety) AND (systematic review OR scoping review OR guideline)

Anchor references: [3], [20], [19], [6]

15. Why dementia travellers fail the mission

Evidence rating	Amber – Good adjacent evidence on BPSD, delirium triggers and dementia transitions; travel-specific outcomes are emerging.
Research-grade question	In travellers or transferred patients with dementia, which modifiable precipitants of behavioural disturbance or delirium during unfamiliar journeys are associated with travel failure or adverse outcomes?
Evidence rating rationale	The travel evidence is still limited, but NICE dementia guidance and hospital dementia intervention reviews support structured assessment for distress causes and environmental triggers.
Best-practice direction to test	Search for both patient triggers and environmental triggers. Separate preventable triggers from non-modifiable dementia severity.
Suggested databases / sources	PubMed, PsycINFO, CINAHL, Cochrane Library, emergency medicine and geriatric psychiatry databases.

Starter search string:

(dementia OR “cognitive impairment”) AND (travel OR transfer OR transport OR “transition of care” OR hospital OR airport OR “unfamiliar environment”) AND (agitation OR “behavioural disturbance” OR BPSD OR delirium OR wandering OR refusal) AND (pain OR urinary retention OR constipation OR dehydration OR hypoxia OR infection OR medication OR sleep) AND systematic[sb]

Anchor references: [6], [21], [20], [19]

16. Dementia travel planning bundle

Evidence rating	Amber – Multicomponent delirium prevention is well supported; the travel-bundle application is indirect.
Research-grade question	For people with dementia undertaking long-distance travel or care transitions, which multicomponent planning interventions reduce delirium, agitation, falls, medication errors, wandering or failed transfer?
Evidence rating rationale	A travel bundle can be evidence-informed by delirium prevention, dementia distress management, caregiver support and transport accessibility research, but the bundle itself should be prospectively audited.
Best-practice direction to test	Bundle components should include orientation, hydration, toileting, sensory aids, medication plan, pain/constipation plan, familiar escort, route simplification and abort criteria.
Suggested databases / sources	PubMed, Cochrane Library, CINAHL, PsycINFO, NICE evidence reviews, Joanna Briggs Institute, transport/accessibility literature.

Starter search string:

(dementia OR “cognitive impairment”) AND (“care transition” OR transfer OR transport OR travel OR “hospital discharge”) AND (“multicomponent intervention” OR planning OR caregiver OR escort OR “environmental intervention” OR “medication management” OR orientation OR hydration OR mobility) AND (delirium OR agitation OR falls OR medication errors OR safety) AND systematic[sb]

Anchor references: [16], [6], [21], [19]

17. Behavioural disturbance: the first-line drug is not a drug

Evidence rating	Green – Guidelines and umbrella-review evidence support non-pharmacological first-line management.
Research-grade question	In people with dementia experiencing agitation or behavioural disturbance, how effective are non-pharmacological assessment and management strategies compared with pharmacological treatment for reducing distress, aggression and need for restraint?
Evidence rating rationale	NICE recommends structured assessment and psychosocial/environmental interventions before antipsychotics. Umbrella-review evidence supports non-pharmacological approaches, while noting heterogeneity by symptom and setting.
Best-practice direction to test	Operationalise the bedside question: pain, pee, poo, panic, hypoxia, hunger, infection, medication toxicity, unfamiliarity or fear.
Suggested databases / sources	Cochrane Library, PubMed, PsycINFO, CINAHL, NICE, AGS/Choosing Wisely, geriatric psychiatry databases.

Starter search string:

(dementia OR Alzheimer*) AND (agitation OR aggression OR “behavioural and psychological symptoms” OR BPSD OR “behavioural disturbance”) AND (“non-pharmacological” OR psychosocial OR environmental OR pain OR “person-centred care” OR de-escalation OR “needs assessment”) AND (antipsychotic* OR benzodiazepine* OR pharmacological OR usual care) AND systematic[sb]

Anchor references: [6], [22], [16]

18. Chemical restraint during movement and flight

Evidence rating	Amber – Good cautionary guidance and harm evidence; transport-specific comparative evidence is limited.
Research-grade question	In older adults with dementia or delirium requiring urgent transport, which pharmacological strategies for severe agitation provide the best balance of behavioural control, respiratory safety, cardiovascular safety and delirium outcomes?
Evidence rating rationale	Guidelines restrict antipsychotics to severe distress or risk of harm; observational data show important harms. ED/EMS scoping evidence identifies a major gap in older adult agitation management and non-restraint alternatives.
Best-practice direction to test	Do not use sedation to make an unsuitable commercial movement appear suitable. Trial medication before travel, document consent/authority, and match monitoring to drug risk.
Suggested databases / sources	PubMed, Cochrane Library, PsycINFO, emergency medicine databases, geriatric psychiatry guidelines, aviation medicine literature.

Starter search string:

(“older adult*” OR elderly OR geriatric*) AND (dementia OR delirium OR “cognitive impairment”) AND (agitation OR aggression OR “behavioural disturbance” OR “acute behavioural disturbance”) AND (antipsychotic* OR haloperidol OR olanzapine OR risperidone OR quetiapine OR benzodiazepine* OR lorazepam OR midazolam OR “chemical restraint”) AND (safety OR respiratory OR falls OR QT OR mortality OR oversedation) AND systematic[sb]

Anchor references: [6], [5], [24], [23]

19. Palliative/last goodbye travellers

Evidence rating	Red – High human importance but sparse systematic evidence; case series, guidance and ethics literature dominate.
Research-grade question	In older adults with advanced cancer or life-limiting illness who wish to travel home or visit family, which clinical, ethical and logistical criteria best guide risk assessment for commercial flight, escorted repatriation or air ambulance transfer near end of life?
Evidence rating rationale	The literature supports structured end-of-life travel planning but is not strong enough to give simple flight/no-flight rules. This is a prime area for case-series synthesis and prospective service audit.
Best-practice direction to test	Frame the decision around survival of the whole journey, symptom control, goal concordance, informed acceptance of risk, receiving clinician/hospice, and contingency planning for deterioration or death.
Suggested databases / sources	PubMed, Embase, CINAHL, PsycINFO, palliative care journals, ethics databases, air medical journals, travel medicine guidance.

Starter search string:

(“advanced cancer” OR “terminal illness” OR “life-limiting illness” OR palliative OR “end of life”) AND (“air travel” OR “commercial flight” OR repatriation OR “medical evacuation” OR “air ambulance” OR “travel home”) AND (risk assessment OR “fitness to fly” OR death OR “symptom control” OR dignity OR ethics OR decision-making) AND (systematic review OR scoping review OR guideline OR qualitative synthesis)

Anchor references: [26], [27], [28], [29]

20. Closing framework: the 6 Cs

Evidence rating	Amber – Strong geriatric assessment evidence; proposed travel framework requires validation.
Research-grade question	In older adults being considered for travel after acute illness, does a structured multidomain framework incorporating capacity, cognition, cardiopulmonary reserve, conditioning, care needs and contingency planning improve safety, decision quality or resource use compared with unstructured clinical judgement?
Evidence rating rationale	CGA has high-certainty evidence for selected outcomes in hospitalised older adults; the 6 Cs are an applied aviation-medicine implementation framework that should be tested by service audit.
Best-practice direction to test	Use the 6 Cs as an audit-ready decision scaffold: capacity, cognition, cardiopulmonary reserve, conditioning, care requirement and contingency.
Suggested databases / sources	PubMed, Cochrane Library, Embase, CINAHL, health services research databases, implementation science literature.

Starter search string:

(“older adult*” OR elderly OR geriatric* OR frail*) AND (“comprehensive geriatric assessment” OR “multidomain assessment” OR “frailty assessment” OR “structured assessment” OR checklist OR “decision support”) AND (travel OR “fitness to fly” OR discharge OR “care transition” OR repatriation OR “medical transport”) AND (safety OR adverse OR readmission OR mortality OR “decision making” OR cost OR “resource use”) AND systematic[sb]

Anchor references: [15], [3], [25], [7]

Reference list

[1] Cochrane Handbook. Cochrane. Chapter 4: Searching for and selecting studies. Cochrane Handbook for Systematic Reviews of Interventions. Source

[2] PubMed Help. National Library of Medicine. PubMed Help: Systematic reviews filter and systematic[sb]. Source

[3] IAG Fit-to-Fly 2025. International Assistance Group. Fit-to-Fly Guidelines. 3rd edition. November 2025. Uploaded briefing source.

[4] WHO dementia. World Health Organization. Dementia fact sheet. 31 March 2025. Source

[5] NICE delirium. NICE. Delirium: prevention, diagnosis and management in hospital and long-term care. Clinical guideline CG103. Last reviewed January 2023. Source

[6] NICE dementia. NICE. Dementia: assessment, management and support for people living with dementia and their carers. Guideline NG97. Source

[7] CDC chronic illness. CDC Yellow Book 2026. Travelers with Chronic Illnesses. Published 23 April 2025. Source

[8] CDC jet lag. CDC Yellow Book 2026. Jet Lag Disorder. Published 23 April 2025. Source

[9] CDC DVT/PE. CDC Yellow Book 2026. Deep Vein Thrombosis and Pulmonary Embolism. Published 23 April 2025. Source

[10] BTS air travel. Coker RK, Armstrong A, Church AC, et al. BTS Clinical Statement on air travel for passengers with respiratory disease. Thorax. 2022;77:329-350. Source

[11] BCS cardiovascular. Smith D, Toff W, Joy M, et al. Fitness to fly for passengers with cardiovascular disease. Heart. 2010;96 Suppl 2:ii1-ii16. Source

[12] Air travel VTE SR. Philbrick JT, Shumate R, Siadaty MS, Becker DM. Air travel and venous thromboembolism: a systematic review. J Gen Intern Med. 2007;22(1):107-114. Source

[13] HAD review. Chen Y, Almirall-Sanchez A, Mockler D, et al. Hospital-associated deconditioning: not only physical, but also cognitive. Int J Geriatr Psychiatry. 2022;37:e5687. Source

[14] Frail HAC review. Umegaki H. Hospital-associated complications in frail older adults. Geriatr Gerontol Int. 2024. Source

[15] Cochrane CGA. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9:CD006211. Source

[16] Cochrane delirium prevention. Burton JK, Craig LE, Yong SQ, et al. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2021;7:CD013307. Source

[17] 4AT diagnostic accuracy. Tieges Z, MacLullich AMJ, Anand A, et al. Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. Age Ageing. 2021;50(3):733-743. Source

[18] Post-ICU cognitive impairment. Ho MH, Lee YW, Wang L. Estimated prevalence of post-intensive care cognitive impairment at short-term and long-term follow-ups: a proportional meta-analysis of observational studies. Ann Intensive Care. 2025;15:31. Source

[19] Dementia-friendly transport. Lanthier-Labonte S, et al. Dementia-Friendly Transportation Services: A Scoping Review. The Gerontologist. 2024;64(7):gnae047. Source

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