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Paper written for the 28th FIMA Scientific Meeting on the Theme "Geriatrics: From basic to clinic to hospital implementation in the paradigm of Islam" held at Yarsi University in Jakarta July 2011 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics, Faculty of Medicine, and Chairman of the Institution Review Board King Fahad Medical City, Riyadh Saudi Arabia. EM omarkasule@yahoo.com, WEB: http://omarkasule-tib.blogspot.com
ABSTRACT
The paper summarizes basic scientific and clinical aspects of old age from an Islamic perspective.
1.0 DEFINITION and CHARACTERISTICS OF OLD AGE, AGE 60-130
1.1 DEFINITIONS
Biological definition: Old age or senescence is the last stage of human life. It is difficult to define ageing exactly. 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 . 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.
Ardhal al ‘umr: This is a stage of extreme weakness and senescence that precedes death mentioned by the Qur’an in two verses . It is a difficult period of weakness, debility and dependence. The prophet prayed to Allah to be spared from this stage of life.
Gerontology is the study of the phenomenon of aging. Gerontology studies social, psychological, physiological, and anatomical aspects of aging. Its aim is not to prolong life but to raise quality of life in old age by minimizing incapacitating conditions. Geriatrics and gerontology have become important disciplines because of increasing longevity
Geriatrics: This is a medical discipline concerned prevention and treatment of disease in the elderly and is part of gerontology.
1.2 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) Controls 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 has decreased fertility rates such that there are fewer young people and older people. (c) Medical technology has caused a decrease of late life mortality so that the elderly now live longer than before.
1.3 QUR'ANIC TERMS FOR OLD AGE:
The Qur'an has described old age, shaykhukha, using the word shaikh in the adjective form . The terms kibr and kabir have been used to indicate growing older . The term haram is also used to refer to old age.
1.4 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 . 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 . 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. The ability to clone organs may also play a role in longevity by replacing failing organs with clones.
1.5 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 . 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.
2.0 PHYSICAL DECLINE IN OLD AGE
2.1 THEORIES OF AGEING
Aging is progressive decline in biological function and adjustment to metabolic stress. It predisposes the person to diseases and debilities. We can talk about aging at various levels: the cell, the organ, and the entire organism. Gerontology is a science that studies factors related to aging. The genetic theories of aging are based on three phenomena: programming of the lifespan in the genes, errors in DNA and RNA mechanisms of information transfer, and mutations. Non-genetic theories of aging are based on wear and tear of tissues, accumulation of toxic wastes in the body, and alterations in the structure and hence function of enzymes. The autoimmune theory of aging is based on the inability of the immune system to distinguish ‘self’ from ‘foreign’ proteins. Heredity is a factor in longevity. Cumulative exposure to natural radiation contributes little to aging but can cause cancer. Infections and malnutrition also contribute to aging.
2.2 CHANGES IN THE CELL
Types of cells and their replicative ability: Cell biology can explain many phenomena of aging. Cells can be classified according to their replication properties. Cells that are continuously renewed are the epithelial cells, spermatozoa, and blood cells. Cells with the potential to proliferate are liver cells, kidney tubules, exocrine glands, endocrine glands, and connective tissues. Cells that are not renewed or replaced are the myocardium, somatic muscle cells, nerve cells, and retinal cells. The capacity for cell division declines with age. This implies that life-span is genetically controlled by mechanisms encoded within the cell. 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 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 accumulation 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 and decreasing ability of the aging body mechanisms to correct the errors.
Cellular ageing: Ageing, 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. Cell division decreases with age. All is deliberate plan by Allah and all is pre-designed.
2.3 CHANGES IN TISSUES AND ORGANS
Over-view: 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. The Qur’an described the degeneration associated with aging . Aging 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 . 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 . 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. Old age is a period of limited work because of physical impairments . This is weakness after the period of youthful strength and energy . 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.
The cardiovascular system: Arteries become fibrous, sclerosed, and less elastic with reduction in performance. The amount of blood pumped decreases by 50% between 20 and 90. Arteriosclerosis increases with age. Blood vessels become less elastic with age. Thickening of the arterial intimal layers leads to narrowing of the arterial lumina. All these changes are accompanied by increase of both systolic and diastolic blood pressures.
The digestive system: Loss of teeth with age leads to difficulties of mastication. Digestion and absorption are not markedly impaired thus nutritional deficiencies in the elderly are due to poor eating habits. The liver loses mass and efficiency.
The nervous system: Structural changes in the brain are not marked however there is loss of some neurons. Neurological problems of the elderly are due to disease such as Alzheimer’s or cerebro-vascular disease. Reflexes become slower and the speed of nervous conduction decreases. The elderly experience impairment of short-term memory and longer response time. They are more cautious and rigid in behavior. They may also withdraw socially. Psychological impairments are due to loss of neurons.
The skin: The skin becomes thin and dry. It loses elasticity. Wrinkles develop. Patches of dark pigmentation appear. Hair grays and becomes thin.
Endocrine system: Reduced utilization of thyroxine leads to lower metabolic rate. There is no decrease in pituitary secretions. The sensitivity of the pancreas to insulin is reduced. Both androgen and estrogen secretion decrease with age. The response of cells to endocrine hormones decreases.
Skeletal system: There is loss of calcium in bones. The bones more fragile and lighter and break easily. There is higher incidence of osteoporosis especially in women. The cartilage covering bones in joints becomes thinner making bones meet and creak on movement. The mobility of joints decreases because of arthritis. Compression of the vertebral column leads to loss of height.
Respiratory system: Vital capacity decreases due to stiffness of the thoracic cage. The lung also becomes less elastic.
Kidney: The kidney loses mass and efficiency. There is decreased concentration of urine and decreased renal blood flow
Homeostatic mechanisms: These remain effective but slower in response.
Sense organs: The eye lens loses elasticity. Visual acuity declines and has to be compensated by using glasses and more illumination. Weakening of ciliary muscles leads to loss of visual accommodation. Some nerve cells and fibers are lost leading to decreased hearing higher tones. Reduced taste is due to atrophy of taste buds.
Striated (skeletal) muscle mass is lost with aging perhaps due to low physical activity. The muscle metabolic rate decreases. Collagen loses its elasticity leading to stiffness.
Other changes: Virtually all tissues undergo various levels of atrophy. Blood vessels lose their elasticity.. Blood-forming stem cells are depleted predisposing the elderly to anemia. Materials such as amyloid and lipofucsin accumulate in the tissues. Impairment of the immune system predisposes the elderly to cancer.
2.4 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 in the elderly is normal and does not need treatment.
3.0 SOCIAL AND PSYCHOLOGICAL ASPECTS
3.1 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 .
3.2 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 .
3.3 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. Mistreatment of parents, ‘uquuq al waalidayn, is a major sin. This covers parents of others. If you mistreat someone’s parent someone else may mistreat your parents.
3.4 ISLAMIC GUIDANCE ON THE ELDERLY:
The prophet spoke a lot about recognizing and respecting the rights of the elderly, ‘irfan haqq al kabir . The elderly have a legal right of physical support by their offspring. The offspring must bear with patience any annoying demands from their parents. The elderly are dependent but very important members of society whose rights must be respected. ‘irfaan haqq al kabiir. 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 . 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.
4.0 CLINICAL DISORDERS OF OLD AGE
4.1 OVERVIEW
Listing the disorders of old age is like making a catalog of all subjects in the textbook of pathology. Anything that can go wrong is found to be wrong in the elderly because of their decreased ability to cope with environmental insults.
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.
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 judgment 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 pharmacokinetics (absorption, metabolism, 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.
4.2 MUSCULO-SKELETAL MOTOR DYSFUNCTION
The Qur'an describes old age as the age of weak bones . The elderly have various degrees of immobility due to muscular, 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). 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 . If the sitting down posture is difficult they can pray lying on the side . Abdullah Ibn Omar did not complete some acts of prayer because of a disability in his foot . In sickness permission is given to omit circumbulation of the kaaba . Circumbulation can be performed on another person's back or a vehicle like a wheel chair. The prophet did circumbulate on an animal . It is offensive, makruh, to circumbulate on an animal for no valid excuse .
4.3 NEUROLOGICAL 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 hypotension occurs limiting their ability to stand up for prolonged periods or to walk. Impaired thermoregulation makes them very vulnerable to sudden changes in environmental temperature. 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.
4.4 PSYCHOSOCIAL DYSFUNCTION
The sleep patterns are altered with insomnia being common. The elderly cannot sleep in the early hours of the morning probably due to depression.
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.
Ibadat: The elderly may not be able to fulfill all the conditions of prayer on account of their mental impairments.
Munakahaat: In extremes of age the pronouncements of the elderly on marriage contracts and divorce may be due to mental confusion.
Mu'amalaat: Restriction may be made on the elderly in transactions if they have mental confusion.
Jinayaat: reliability of evidence of the elderly is questionable if they have confusional states. Criminal liability of the elderly for actions may be limited.
Psychosocial function: Old age is a period of psychological stress because of the dependency status it engenders. Previously active and self-directed individuals feel loss of independence keenly. 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.
Sexual function: Old age is looked at for both males and females as a period of declining reproductive ability . 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. In old age males may suffer from impotence due to erectile difficulties. Vaginitis in females is due to deficient estrogens making sexual intercourse painful.
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. An elderly person is exempted from fasting if it will hurt good health.
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ABSTRACT
The paper summarizes basic scientific and clinical aspects of old age from an Islamic perspective.
1.0 DEFINITION and CHARACTERISTICS OF OLD AGE, AGE 60-130
1.1 DEFINITIONS
Biological definition: Old age or senescence is the last stage of human life. It is difficult to define ageing exactly. 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 . 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.
Ardhal al ‘umr: This is a stage of extreme weakness and senescence that precedes death mentioned by the Qur’an in two verses . It is a difficult period of weakness, debility and dependence. The prophet prayed to Allah to be spared from this stage of life.
Gerontology is the study of the phenomenon of aging. Gerontology studies social, psychological, physiological, and anatomical aspects of aging. Its aim is not to prolong life but to raise quality of life in old age by minimizing incapacitating conditions. Geriatrics and gerontology have become important disciplines because of increasing longevity
Geriatrics: This is a medical discipline concerned prevention and treatment of disease in the elderly and is part of gerontology.
1.2 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) Controls 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 has decreased fertility rates such that there are fewer young people and older people. (c) Medical technology has caused a decrease of late life mortality so that the elderly now live longer than before.
1.3 QUR'ANIC TERMS FOR OLD AGE:
The Qur'an has described old age, shaykhukha, using the word shaikh in the adjective form . The terms kibr and kabir have been used to indicate growing older . The term haram is also used to refer to old age.
1.4 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 . 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 . 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. The ability to clone organs may also play a role in longevity by replacing failing organs with clones.
1.5 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 . 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.
2.0 PHYSICAL DECLINE IN OLD AGE
2.1 THEORIES OF AGEING
Aging is progressive decline in biological function and adjustment to metabolic stress. It predisposes the person to diseases and debilities. We can talk about aging at various levels: the cell, the organ, and the entire organism. Gerontology is a science that studies factors related to aging. The genetic theories of aging are based on three phenomena: programming of the lifespan in the genes, errors in DNA and RNA mechanisms of information transfer, and mutations. Non-genetic theories of aging are based on wear and tear of tissues, accumulation of toxic wastes in the body, and alterations in the structure and hence function of enzymes. The autoimmune theory of aging is based on the inability of the immune system to distinguish ‘self’ from ‘foreign’ proteins. Heredity is a factor in longevity. Cumulative exposure to natural radiation contributes little to aging but can cause cancer. Infections and malnutrition also contribute to aging.
2.2 CHANGES IN THE CELL
Types of cells and their replicative ability: Cell biology can explain many phenomena of aging. Cells can be classified according to their replication properties. Cells that are continuously renewed are the epithelial cells, spermatozoa, and blood cells. Cells with the potential to proliferate are liver cells, kidney tubules, exocrine glands, endocrine glands, and connective tissues. Cells that are not renewed or replaced are the myocardium, somatic muscle cells, nerve cells, and retinal cells. The capacity for cell division declines with age. This implies that life-span is genetically controlled by mechanisms encoded within the cell. 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 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 accumulation 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 and decreasing ability of the aging body mechanisms to correct the errors.
Cellular ageing: Ageing, 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. Cell division decreases with age. All is deliberate plan by Allah and all is pre-designed.
2.3 CHANGES IN TISSUES AND ORGANS
Over-view: 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. The Qur’an described the degeneration associated with aging . Aging 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 . 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 . 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. Old age is a period of limited work because of physical impairments . This is weakness after the period of youthful strength and energy . 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.
The cardiovascular system: Arteries become fibrous, sclerosed, and less elastic with reduction in performance. The amount of blood pumped decreases by 50% between 20 and 90. Arteriosclerosis increases with age. Blood vessels become less elastic with age. Thickening of the arterial intimal layers leads to narrowing of the arterial lumina. All these changes are accompanied by increase of both systolic and diastolic blood pressures.
The digestive system: Loss of teeth with age leads to difficulties of mastication. Digestion and absorption are not markedly impaired thus nutritional deficiencies in the elderly are due to poor eating habits. The liver loses mass and efficiency.
The nervous system: Structural changes in the brain are not marked however there is loss of some neurons. Neurological problems of the elderly are due to disease such as Alzheimer’s or cerebro-vascular disease. Reflexes become slower and the speed of nervous conduction decreases. The elderly experience impairment of short-term memory and longer response time. They are more cautious and rigid in behavior. They may also withdraw socially. Psychological impairments are due to loss of neurons.
The skin: The skin becomes thin and dry. It loses elasticity. Wrinkles develop. Patches of dark pigmentation appear. Hair grays and becomes thin.
Endocrine system: Reduced utilization of thyroxine leads to lower metabolic rate. There is no decrease in pituitary secretions. The sensitivity of the pancreas to insulin is reduced. Both androgen and estrogen secretion decrease with age. The response of cells to endocrine hormones decreases.
Skeletal system: There is loss of calcium in bones. The bones more fragile and lighter and break easily. There is higher incidence of osteoporosis especially in women. The cartilage covering bones in joints becomes thinner making bones meet and creak on movement. The mobility of joints decreases because of arthritis. Compression of the vertebral column leads to loss of height.
Respiratory system: Vital capacity decreases due to stiffness of the thoracic cage. The lung also becomes less elastic.
Kidney: The kidney loses mass and efficiency. There is decreased concentration of urine and decreased renal blood flow
Homeostatic mechanisms: These remain effective but slower in response.
Sense organs: The eye lens loses elasticity. Visual acuity declines and has to be compensated by using glasses and more illumination. Weakening of ciliary muscles leads to loss of visual accommodation. Some nerve cells and fibers are lost leading to decreased hearing higher tones. Reduced taste is due to atrophy of taste buds.
Striated (skeletal) muscle mass is lost with aging perhaps due to low physical activity. The muscle metabolic rate decreases. Collagen loses its elasticity leading to stiffness.
Other changes: Virtually all tissues undergo various levels of atrophy. Blood vessels lose their elasticity.. Blood-forming stem cells are depleted predisposing the elderly to anemia. Materials such as amyloid and lipofucsin accumulate in the tissues. Impairment of the immune system predisposes the elderly to cancer.
2.4 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 in the elderly is normal and does not need treatment.
3.0 SOCIAL AND PSYCHOLOGICAL ASPECTS
3.1 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 .
3.2 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 .
3.3 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. Mistreatment of parents, ‘uquuq al waalidayn, is a major sin. This covers parents of others. If you mistreat someone’s parent someone else may mistreat your parents.
3.4 ISLAMIC GUIDANCE ON THE ELDERLY:
The prophet spoke a lot about recognizing and respecting the rights of the elderly, ‘irfan haqq al kabir . The elderly have a legal right of physical support by their offspring. The offspring must bear with patience any annoying demands from their parents. The elderly are dependent but very important members of society whose rights must be respected. ‘irfaan haqq al kabiir. 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 . 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.
4.0 CLINICAL DISORDERS OF OLD AGE
4.1 OVERVIEW
Listing the disorders of old age is like making a catalog of all subjects in the textbook of pathology. Anything that can go wrong is found to be wrong in the elderly because of their decreased ability to cope with environmental insults.
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.
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 judgment 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 pharmacokinetics (absorption, metabolism, 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.
4.2 MUSCULO-SKELETAL MOTOR DYSFUNCTION
The Qur'an describes old age as the age of weak bones . The elderly have various degrees of immobility due to muscular, 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). 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 . If the sitting down posture is difficult they can pray lying on the side . Abdullah Ibn Omar did not complete some acts of prayer because of a disability in his foot . In sickness permission is given to omit circumbulation of the kaaba . Circumbulation can be performed on another person's back or a vehicle like a wheel chair. The prophet did circumbulate on an animal . It is offensive, makruh, to circumbulate on an animal for no valid excuse .
4.3 NEUROLOGICAL 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 hypotension occurs limiting their ability to stand up for prolonged periods or to walk. Impaired thermoregulation makes them very vulnerable to sudden changes in environmental temperature. 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.
4.4 PSYCHOSOCIAL DYSFUNCTION
The sleep patterns are altered with insomnia being common. The elderly cannot sleep in the early hours of the morning probably due to depression.
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.
Ibadat: The elderly may not be able to fulfill all the conditions of prayer on account of their mental impairments.
Munakahaat: In extremes of age the pronouncements of the elderly on marriage contracts and divorce may be due to mental confusion.
Mu'amalaat: Restriction may be made on the elderly in transactions if they have mental confusion.
Jinayaat: reliability of evidence of the elderly is questionable if they have confusional states. Criminal liability of the elderly for actions may be limited.
Psychosocial function: Old age is a period of psychological stress because of the dependency status it engenders. Previously active and self-directed individuals feel loss of independence keenly. 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.
Sexual function: Old age is looked at for both males and females as a period of declining reproductive ability . 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. In old age males may suffer from impotence due to erectile difficulties. Vaginitis in females is due to deficient estrogens making sexual intercourse painful.
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. An elderly person is exempted from fasting if it will hurt good health.
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[1] Bukhari Kitaab al Riqaaq
[2] Qur'an 16:70, 27:5
[3] Qur'an 3:40, 11:72, 12:78, 16:70, 19:4, 22:5, 26:171, 28:23, 30:54, 37:135, 40:67, 51:29
[4] Qur'an 2:266, 3:40, 4:6, 12:78, 14:39, 15:54, 17:23, 19:8, 28:23
[5] Muslim Hadith #6438, Muslim Hadith #6440
[6] Mukhtasar Bukhari Hadith # 368
[7] Qur'an 2:90, Qur'an 2:96, Muslim Kitaab #12 Hadith #113-119
[8] Qur'an 36:68
[9] Qur'an 16:70; 22:5; Mukhtasar Bukhari Hadith #1750
[10] Mukhatasar Bukhari Hadith #2096
[11] Qur'an 28:23
[12] Qur'an 30:54, 40:67
[13] Mukhtasar Bukhari Hadith #2096
[14] Mukhtasar Bukharu Hadith #1750
[15] Tirmidhi Kitaab #25 Baab #15
[16] Bukhari Kitaab #78 Baab #1
[17] Qur'an 19:4
[18] Bukhari Kitaab #8 Baab #18
[19] Bukhari Kitaab #18 Baab #19
[20] Muwatta Kitaab #3 Hadith #49
[21] Muwatta Kitaab #20 Hadith #250)
[22] Bukhari Kitaab #8 Baab #78
[23] Muwatta Kitaab #20 Hadith #130)
[24] Qur'an 3:40, 11:72