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Lecture to 2nd year medical students at the Kulliyah of Medicine, International Islamic University, Kuantan, Malaysia on 23rd January 1999 by Prof Omar Hasan Kasule, Sr.
OUTLINE
THE CONCEPT OF OLD AGE
Definition & nature of aging
Demographic change
Qur'anic terms for old age
Start of old age
Human life-span
Human desire for long life
CELLULAR BASIS OF AGING
Types of cells and their replicative ability
Errors in cell division
Cellular aging
CHANGES IN AGING
Physical and other changes in aging
The Concept of homeostenosis
Quality of life in old age
Physical impairments
Autonomic dysfunction
Physiological and biochemical impairments
Sexual function
Nutrition
Sleep disorders
Mental impairments
Psycho-social
LEGAL EXEMPTIONS
Taharat
Acts of physical worship (ibadat):
Jihad
Sexual function
Rights and obligations
Legal rights of physical support
GERIATRIC MEDICINE
Balance
Care for the elderly: institutional vs home care
GOOD TREATMENT OF PARENTS
birr al waalidayn)
Duties to parents
uquuq al walidayn
Abuse/mistreatment of the elderly
Rights of the elderly, haqq al al kabir
ETHICAL ISSUES OF OLD AGE
Prevention
Health resource allocation
THE CONCEPT OF OLD AGE (SHAYKHUUKHAT, KIBR, HARAM, AGE 60-130)
Definition: It is difficult to define aging exactly. Aging 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 aging. 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 take this into consideration. 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.
Nature of aging: It is difficult to define aging exactly. Aging is a natural process. It is a long and variable process with much individual variation. Factors that affect the rate and extent of aging are: genetic variability, environmental insults, accumulation of changes in somatic cells, mutations and chemical damage. 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 take this into consideration. The elderly are old and not necessarily sick.
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 old 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 described 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).
Start of old age: The age of 60 has a special meaning (KS p. 402). 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. Allah does not excuse any sins above 60 years of age (MB # 2095 p 982).
Human life-span: Each animal or plant species has a typical life span that varies with environmental conditions. Within humans and animals, the female life-span is generally higher than the male. Typical life-span 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 (MB #368, MB # 96 p 101). The age of 100 is however not the upper ceiling and the possibility of longer life-span is possible. The Qur'an tells us about 2 exceptions to the average life-span 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 life-span can change. There are gender and ethnic differences in longevity. All these indicate the possibility of life-span 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, KS 106). 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.
CELLULAR BASIS OF AGING
Types of cells and their replicative ability: 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, and 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 are not known. 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 aging 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 aging: 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. With age the following phenomena increase and their cumulative effects lead to aging or death of the cell: the accumulation of somatic mutations, error rates in protein synthesis, and failure of correcting mechanisms.
CHANGES IN AGING
Physical and other changes in aging. Aging in accompanied by physical, psychological and social changes as well as challenges. 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, Mukhtasar Sahih al Bukhari # 1750, KS 79). 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 (Mukhtasar Sahih al Bukhari # 2096). 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.
The Concept of homeostenosis: Homeostasis is the state in which the body systems are in perfect harmony and balance. It is a dynamic concept rather than a static one. There are always disturbances to the homeostatic order but the body has corrective mechanisms that return it to the previous state almost instantly. This corrective ability declines gradually with age. The term homeostenosis is used to describe the declining ability to maintain the homeostatic order as compensatory mechanisms become impaired.
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.
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 aging and pathology is very fine. Eye accommodation is impaired leading to presbyopia. This is due to decreasing elasticity of the lens capsule and the thickening of the lens. Decline in the ears results in loss of high frequency hearing (presbyacusis). Bone loss starts from the age of 35 years and osteoporosis increases with age. The Qur'an describes old age as the age of weak bones (19:4). The elderly have various degrees of immobility due to mascular, joint and bone degeneration. Their limited mobility is also associated with instability. The elderly are prone to falling and other accidents because of blurred vision and loss of balance (poor propioception & vestibular lesions).
Autonomic dysfunction: Functional impairments in many organs occur due to imbalances in the autonomic nervous system. The elderly may suffer from urinary or fecal incontinence. They may also suffer from urinary or fecal retention. Postural hypo-tension occurs limiting their ability to stand up for prolonged periods or to walk. Impaired thermo-regulation makes them very vulnerable to sudden changes in environmental temperature.
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.
Sexual function: Old age is looked at for both males and females as a period of declining reproductive ability (3:40, 11:72). Their sexual function is reduced due to anatomical changes or autonomic dysfunction. Reduction of sexual function may not be accompanied by reduction of sexual desire.
Nutrition: Elderly malnutrition is common. The nutritional intake is lower because of poverty, inability to prepare and consume food or just loss of appetite. Nutritional deficiencies are also common due to unbalanced diets.
Sleep disorders: The sleep patterns are altered with insomnia being common. The elderly can not sleep in the early hours of the morning probably due to depression.
Mental impairments: The elderly may suffer from various types and degrees of intellectual impairment. Alzheimer's disease is the commonest cause of intellectual decline. This manifests as cognitive impairment, memory loss, and reduced or distorted environmental sensory input. The cognitive impairment is due to decline of speed of information processing. This reduces fluid intelligence, the ability to solve new problems. Memory loss is more pronounced for recent than for long-term memory. The experience and accumulated knowledge of the elderly sometimes more than compensates for the cognitive decline. Many elderly are functioning very well intellectually well into their 90s.
Psycho-social: Old age is a period of psychological stress because of the dependency status it engenders. Loss of independence is felt keenly by previously active and self-directed individuals. There is loss of self-esteem. Socially the elders suffer from the stress of reduced social interaction and loss of income. In many communities the elderly live in poverty. On the other hand there are a few elderly who enjoy their last years of life. These are generally in good health or have accepted their physical impairments. They usually feel they have accomplished their mission in life. In a stage of actualization, they have no more ambitions or challenges to face and there do not feel the frustrations and stresses of the young.
LEGAL EXEMPTIONS
Taharat: Urinary incontinence and fecal incontinence may make it difficult for the elderly to maintain a state of ritual purity, wudhu, for long enough to complete the prayers. They are allowed to wear a diaper or urinary retainer, make wudhu, and pray immediately. They do not have to repeat the prayer because of any incontinence that they may experience.
Acts of physical worship (Ibadat): The elderly, like the sick, are exempted from fulfilling all the acts and conditions of the physical acts of ibadat, salat, saum, and hajj. The elderly can pray sitting down (KS 310). If the sitting down posture is difficult they can pray lying on the side (KS 310). Abdullah Ibn Omar did not complete some acts of prayer because of a disability in his foot (KS 367). An elderly person is exempted from fasting if it will hurt good health (KS 334). In sickness permission is given to omit circumbulation, tawaf, of the kaaba (KS 352). Circumbulation can be performed on another persons's back or a vehicle like a wheel chair. The prophet did circumbulate on an animal (KS 352). It is offensive, makruh, to circumbulate on an animal for no valid excuse.
Jihad: The elderly are exempted from the obligation of jihad because of their physical impairment. If the elderly have only one son to look after them, they are entitled to deny him permission to go to jihad.
Sexual function: In old age males may suffer from impotence due to erectile difficulties. Vaginitis in females due to deficient estrogens makes sexual intercourse painful.
Rights and obligations: 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.
Legal rights of physical support: The offspring, relatives and society in general is enjoined to respect the rights of the elderly, irfan haqq al kabir (KS 68). The elderly have a legal right of physical support by their offspring (KS 576). If the offspring neglect this duty and their parents are suffering, the state can confiscate wealth for the maintenance of the elderly parents.
GERIATRIC MEDICINE
Balance: Geriatric medicine is a rapidly-growing discipline due to the increasing longevity. A balance must be established between what is considered the normal physiology of aging (requiring no intervention) and pathology in old age (requiring intervention). The physician must make a judgement on whether diagnostic and therapeutic measures planned will not make the prognosis worse. Care must be taken in prescriptions. The elderly are on several medications because of their multiple pathologies and drug interactions are common. Adverse drug reactions may be more severe in the elderly. The elderly have altered pharmaco-kinetics (absorption, metabolism, and excretion).
Care for the elderly: Routine screening of the elderly is very useful to discover problems early and deal with them. Rehabilitation is a multi-disciplinary effort involving physicians, nurses, physiotherapists, social workers, and psychologists. Members of the family must be an integral part of the team that cares for the elderly. There is a debate between home care vs institutionalization. Home care would be the best because it gives the elderly more feeling of dignity and personal worth.
GOOD TREATMENT OF PARENTS
Good treatment of parents (birr al waalidayn): The Qur'an has in many verses enjoined good treatment of parents, birr al waalidayn (p 188 2:83, 2:215, 4:36, 6:151, 17:23-24, 29:8, 31:14-15, 46:15-18). Good treatment of parents is one of the most loved work to Allah (KS 247) and is a reason for entering heaven (KS 247) Good treatment covers both the father and the mother, wasiyyat bi al ab wa al umm (KS 247). Birr al walidayn includes doing good for them, ihsaan ila al aba. (p 1 2:83, 4:36, 6:151, 17:23, 46:15), honoring them, takrim al aba (p 1 12:99-100), praying for them, dua li al aba (p 1 9:114, 19:47, 26:86, 60:4), and extending the good treatment to their friends (KS 247). The friends must be respected during the life and after the death of the parents.
Duties to parents: Parents must be respected and never shown any contempt whatever their behavior. Each spouse should show consideration to the parents of the other spouse like his or her own parents. Talking to parents must be polite. Ibrahim (PBUH) was polite with his non-believing father. Righteous parents should be followed (p 12 2:133, 12:38). Parents must be obeyed as long as they do not order committing a sin (p 14 37:101-102). Their reputation and wealth must be kept. Attempts must be made to do what pleases them. They must be consulted and apologies must be offered them if for some reason their advice can not be followed. There must be an immediate response when parents call. Kindness and generosity to parents in their senility and weakness is only a partial repayment of their efforts when the children were young. Gratitude for the parents' suffering and sacrifices must be shown.
Mistreatment of parents, uquuq al walidayn:.Parents can not be abused, insulted, or cursed.. Cursing or mistreating, uquuq, parents is considered one of the major sins, kabair, and leads to severe punishment (KS 248). Allah responds to parents' dua against their children (KS 248). The voice should not be raised in the presence of parents. Parents must always be told the truth and no lies should ever be told to them whatever the excuse. The grand-children and spouses can not be preferred above parents in any situation. Generosity must be extended to parents; miserliness to them should be avoided. Parents of others should never be mistreated or insulted. They may insult your parents as a return and you will have caused injury to your own parents.
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 (KS 402). 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 (KS p. 247-248).
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.
ETHICAL ISSUES OF OLD AGE RESEARCH
The ethical issues of research on aging and its prevention: There is basically no ethical problem in the scientific research on cell aging as well as epidemiological studies on risk factors of senescence. What matters is the intention behind the research and to what use that research will be put. If the underlying intention is to prevent or delay death, the research is not ethical. The life-span is fixed for each individual and can not be changed. If the intention of the research is to understand the aging process so that preventive measures can be taken to maintain as high a quality of life as possible, then such research is ethical and is acceptable. Present epidemiological and cell biological knowledge indicates that many measures can be taken to control the aging process. Better nutrition (especially green vegetables and fruits), early detection and treatment of disease, sheltering from cosmic radiation and other environmental exposures, can delay the aging process. This does not however delay the ajal because any other competing cause of death could operate.
Ethics of health resource allocation: In an era of scarce resources, arguments have been made that the elderly consume disproportionately high resources. It may also be argued that the economic utility of the elderly is low. This is most unethical. The elderly have as much right to health care resources as are the young. The difference may lie in the fact that the elderly may not benefit from some some measures in which case it is not useful to undertake them.