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Lecture to 2nd year medical students on 13th October 2000 by Professor Omar Hasan Kasule Sr.
A. DEFINITION and CHARACTERISTICS OF OLD AGE, AGE 60-130
DEFINITION
Biological definition: It is difficult to define ageing exactly. Ageing is a natural process. It is a long and variable process with much individual variation. Genetic, social, dietary, and disease factors determine the rate and extent of ageing. Old age has physical, social, and religious dimensions. Old age is associated with degeneration and decreased or deranged physiological function. It is not true that old age is illness. The changes seen are part of a natural process. A practical definition of disease in the elderly must distinguish between the normal changes of aging and pathological conditions.
Social definition: On the social level, old age also represents the close of the family cycle with the old generation bowing out to be replaced by the new one in the reproductive process. It is also the period of maximum wisdom after internalizing a lot of experiences in life. Reaching old age is an achievement. It is celebrating the end of life’s work and preparing for transition to another life.
Start of old age: The age of 60 has a special meaning; if someone reaches the age of 60 he has no right to ask Allah for a new lease of life (KS 402: Bukhari Kitaab al Riqaaq B 5q; Tirmidhi Kitaab al Zuhd B 23; MB2095: Bukhari-E Vol8 H428). The age of 60 is generally taken to be the start of old age. By this time a person is expected to have passed through many experiences and to have attained wisdom..
DEMOGRAPHIC CHANGE:
The proportion of the elderly in most human populations is increasing. General socio-economic improvement and medical technology have caused this demographic shift in three ways: (a) control of infectious disease and better nutrition have decreased infant mortality, a major determinant of life expectancy. (b) availability of effective contraceptives and the desire for smaller families have decreased fertility rates such that there are fewer young people and more older people. (c) medical technology has caused a decrease of late life mortality so that the elderly now live longer than before.
QUR'ANIC TERMS FOR OLD AGE:
The Qur'an has decribed old age, shaykhukha, using the word sheikh in the adjective form (3:40, 11:72, 12:78, 16:70, 19:4, 22:5, 26:171, 28:23, 30:54, 37:135, 40:67, 51:29). The terms kibr and kabir have been used to indicate growing older (2:266, 3;40, 4:6, 12:78, 14:39, 15:54, 17:23, 19:8, 28:23).
HUMAN LIFE-SPAN:
Each animal or plant species has a typical life span that varies with environmental conditions. Within humans and animals, the female lifespan is generally higher than the male. Typical lifespan also varies by ethnic group, geographical location, and other socio-demographic variables. A hereditary component is also involved since parental longevity in humans has been observed to affect the longevity of the offspring. The life-span of each individual is fixed by Allah (Muslim #6438, 6440). No human effort or endeavor will alter the span. When the appointed hour arrives death ensues. From the historical record and also from study of living communities we know that the maximum human life span does not go much above 100 years. Life beyond the age of 100 years is rare (MB368: Bukhari-E Vol 1 H575, MB96: Bukhari-E Vol 1 H116). The age of 100 is however not the upper ceiling and the possibility of longer life-spans is possible. The Qur'an tells us about 2 exceptions to the average lifespan mentioned above. The Prophet Nuh (PBUH) lived over 900 years. The Prophet Isa (PBUH) who was carried alive to heaven is now aged over 2000 years. The observation of increasing life expectancy at birth in all communities where socio-economic and health conditions have improved is another indication that the lifespan can change. There are gender and ethnic differences in longevity. All these indicate the possibility of lifespan variation upwards or downwards. The steadily increasing life expectancy has given hope of increasing human longevity by controlling causes of aging. Research at the cellular, clinical, and epidemiological levels is being undertaken on aging with this purpose in mind.
HUMAN DESIRE FOR LONG LIFE:
Longevity has always been a desirable objective of humans of all ages and all places. The desire for long life is very strong in most individual humans (2:90, KS106: Bukhari K81 B10,11; Muslim K12 H113-119; Tirmidhi K34 B27, 28; Darimi K20 B62; Ahmad 2:338, 339, 358, 379, 380, 393, 443, 337, 501; Ahmad 3: 115, 119, 122, 168, 169, 176, 192, 198, 236, 238, 247, 256, 272, 275, 340, 341, 456, 460; Ahmad 5: 117, 131, 132, 218; Ahmad 6:55; Tayalisi H1983, 2005). The primary motivation for prevention and cure of disease is to achieve longevity. Humans of all ages have desired youth and looked for the elixir of permanent youthfulness. Thus attempts to find the causes of aging in order to delay and if possible prevent it serve to perpetuate human kind as much as possible. Longer life has advantages. There is more to contribute to society, to do good deeds to expiate for past failures. However the physical disabilities of old age reach a point when they outweigh the psychological and social advantages. This is the point of life that the Prophet (PBUH) referred to as ardhal al 'umr.
B. PHYSICAL DECLINE
TYPES OF CELLS AND THEIR REPLICATIVE ABILITY: (BOWMAN P 4.7)
Cell biology can explain many phenomena of aging. Cells can be classified according to their replication properties. (a) Cells that are continuously renewed: epithelial cells, spermatozoa, blood cells. (b) cells with the potential to proliferate: liver, kidney tubules, exocrine glands, endocrine glands, connective tissue (c) cells not renewed or replaced: myocardium, somatic muscle cells, nerve cells, and retinal cells. The capacity for cell division declines with age. Embryonic cells can divide up to a total of 50 times thus one embryonic cell can over its life-span produce 10E15 cells. Mature cells are capable of fewer divisions; the older they are they less divisions they can make. The reasons for this loss of division capacity is not known but it seems to be part of genetic programming. Cells can increase in number by mitotic division (hyperplasia) or may increase in size without increase in number (hypertrophy). They can also undergo meiotic division. With age the number of irreplaceable cells decreases through the normal process of tear and wear.
ERRORS IN CELL DIVISION:
Let us start by clarifying the term error. Nothing can be an error in the function of the cell. All is deliberate plan by Allah and all is pre-designed. With age the following phenomena increase and their cumulative effects lead to ageing or death of the cell: the cumulation of somatic mutations, error rates in protein synthesis, and failure of error-correcting mechanisms. The increase in these phenomena is due to cumulative environmental insults.
CELLULAR AGEING:
Aging, degeneration, and eventual death can be explained at the cellular level. Aging starts with the cells. Normal cells age and die and others take their place. Cellular function declines gradually with age. There is decline of oxidative phosphorylation, DNA and RNA synthesis, synthesis of proteins and cell receptors. Aging cells have definite morphological changes that distinguish them from the younger cells. The causes of cellular aging are: (a) endogenous molecular program of cell senescence (b) wear and tear is a result of damage by free radicals, post-translational modification of intracellular and extra-cellular proteins, and alterations in the induction of heat-shock proteins. The cells are also damaged by accumulation of adverse changes that may happen randomly or under the influence of environmental insults. Nothing can be an error in the function of the cell. All is deliberate plan by Allah and all is pre-designed.
CHANGES IN AGING:
Aging in accompanied by physical, psychological and social changes as well as challenges (3). There is no point in time when development ceases and degeneration starts. The two processes are contemporaneous. In advanced age degeneration becomes predominant. Normal aging is a gradual process of physical decline and degeneration. It affects the structure and function of all organs. Old age because of its multiple incapacities is sometimes not a pleasant period. The Prophet (PBUH) prayed not to live to advanced age al ta'awudh min ardhal al 'umr (16:70; 22:5; MB1750: Bukhari-E Vol6 H230; KS79: Bukhari K80 B37, 39, 41, 42; Muslim K48 H50-52; Abudaud K29 H4; Nisai K50 B6, 33, 39, 40, 61; Ibn Majah K34 B2; Ahmad 3:113, 117, 122, 179, 201, 205, 208, 214, 220, 226, 231, 235, 240, 264; Ahmad 4:371). Some people with physical aging may psychologically be young. The Prophet mentioned that some people stay young in 2 aspects: love of the world and long hopes (MB2096: Bukhari-E Vol8 H429). Some of those who are physically young may feel and behave like elderly people. There are social aspects in aging. The elderly lose their autonomy and are dependent physically and emotionally. Physical impairments: Old age is a period of limited work because of physical impairments (28:23). This is weakness after the period of youthful strength and energy (30:54, 40:67). Physical decline starts from the age of 30. There is functional decline in the performance of all organs of the body. The difference between the normal physiology of ageing and pathology is very fine. Physiological and biochemical impairments: Biochemical homeostasis is impaired in the elderly. Control of serum glucose is impaired. Serum sodium concentration rises and urine osmolality decline due to impaired osmo-regulation. Interpretation of results of chemical pathology must take these changes into consideration.
QUALITY OF LIFE IN OLD AGE:
The issue of quality is relevant in discussions of longevity. As people age, the quality of their life deteriorates. With increasing longevity new physical problems will appear that lower the quality of life. It is possible that with better understanding of the aging process, procedures will be available to maintain or even improve quality of life in the elderly.. Epidemiological studies have shown that physical activity even in moderation reduces morbidity, protects against neoplasia and aging. Prompt diagnosis and treatment of disease has a positive impact on the quality of life. It is wrong to assume that such disease is normal and does not need treatment.
RIGHTS OF THE ELDERLY, HAQQ AL AL KABIR:
The elderly are dependent but very important members of society whose rights must be respected. It is a grave sin to neglect these rights ( ). They have a right to be treated with extra care because of their dependent status. Children are enjoined to treat their parents well in their old age, birr al waalidayn, and this is considered among the best of endeavors, min ahabb al a’amaal ‘inda al laah birr al walidayn.(Bukhari K78 B1 q3; Abudaud K40 B119; Trimidhi K25 B2). The legal rights and obligations of the elderly may be restricted because of their intellectual impairment. The elderly experience confusional states that cloud their ability to make correct decisions about their person and their wealth. However each case should be examined on its own merits. Some of the elderly remain intellectually competent until the last.
C. SOCIAL AND PSYCHOLOGICAL ASPECTS
AGING IS PSYCHOLOGICAL:
A person is psychologically as old as he feels. An elderly person may feel young. The prophet mentioned that people stay young in 2 ways: love of the world and long hopes (MB2096: Bukhari Vol8 H429).
AGING IS UNPLEASANT
Old age in unpleasant for several reasons. Physical incapacities reduce independence. Accumulated negative life experiences with no hope of returning and doing things again. Prophet prayed not to live to ardhal al umr (MB1750: Bukhari Vol6 H230).
D. ABUSE/MISTREATMENT OF THE ELDERLY:
Materialistic societies do not respect elders because it is felt that they are unproductive and are a burden on society. This is a major transgression (dhulm). They were productive at a time and the new generation was at that time dependent children.
E. ISLAMIC GUIDANCE ON THE ELDERLY:
Rights of the elderly: irfan haqq al kabir (KS576: Tirmidhi 25 B15; Ahmad 2: 207, 222). The elderly have a legal right of physical support by their offspring ()