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THE BIOLOGICAL AND CLINICAL ASPECTS OF OLD AGE: AN ISLAMIC PERSPECTIVE

Dr. Omar Hasan Kasule, MB ChB (MUK), MPH (Harvard), Dr.PH (Harvard)

Professor of Epidemology and Bioethics,Faculty of Medicine

Chairman, The Institution Review BoardKing Fahd Medical City, Ryadh, Saudi Arabia

Presented at Seminar on: Geriatrics: from basic to clinic to hospital implementation in the paradigm of Islam

Jakarta, 16 September 2011

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DEFINITIONS AND CHARACTERISTICS OF OLD AGE

BIOLOGICAL DEFINITION: Old age or senescence is the last stage of human life * its rate and extent are depended to genetic,social, dietary and diseases * is associated with degeneration and deacrease or deranged physiological functions * is not an illness * should be distinguished between normal changes and pathological conditions

SOCIAL DEFINITION: Old generation is replaced by the new one * the period of maximum wisdom * reaching old age is an achievement * transition to another life

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START OF OLD AGE: 60 years

ARDHAL al ‘UMR: A stage of extreme weakness and senescence that precedes death the Prophet prayed to Allah to be spared from this stage of life

GERONTOLOGY: The study of the phenomenen of aging covers social, psychological and anatomical aspects of aging the aim is not to prolong life but to raise quality of life in old age

GERIATRICS: A medical discipline concerned prevention and treatment of disease in the elderly is part of gerontology

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DEMOGRAPHIC CHANGE: General socio-economic improvement and medical technology have caused demographic shift a.o due to: * better control of infectious diseases and better nutrition * availability of effective contraceptives decreased fertility rate smaller family * medical technology has caused an increase of life expectancy

QUR’ANIC TERMS FOR OLD AGE: * shaykhukha using the word shaikh in the adjective form * kibr and kabir used to indicate growing older * haram is also used to refer to old age

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HUMAN LIFE SPAN:

* varies by ethnic group, geographical location, socio-economic, demographic, health, gender and hereditary variables * life span of each individual is fixed by Allah * maximum human life span does not go much above 100 years beyond 100 years are very rare * human longevity could be increased by controlling causes of aging or by replacing organs with clones * in the Qur’an there are verses that there are 2 exceptions: ** the ageof Prophet Nuh (PBUH) is 950 years ** the age of the Prophet Isa (PBUH) who was carried alive to heaven is now aged over 2000 years

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HUMAN DESIRE FOR LONG LIFE:

* Longer life has advantages: ** more contribution to society ** more doing good deeds to expiate for past failures

* Ardhal al-umr is a point of old age where physical disabilities of old age outweigh the psychological and social advantages

7THEORIES OF AGING:

1. Genetic theories: based on 3 phenomena: 1.1. Programming of the life span in the genes heredity 1.2. Errors in DNA 1.3. RNA mechanism of information transfer and mutation

2. Non-genetic theories: based on 2.1. Wear and tear of tissues 2.2. Accumulation of toxic wastes in the body 2.3. Alterations in the structure and function of enzymes

3. Autoimmune theory: based on the inability of the immune system to distinguish “self” from “foreign” proteins

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CHANGES IN THE CELL:

1. Types of cells and their replicative ability: 1.1. Cell s that are continuously renewed: epithel, spermatozoa, and blood cells 1.2. Cells with potential to proliferate: liver, kydney tubules, exocrine glands, endocrine glandsand connective tissues 1.3. Cells that are not renewed or replaced: myocardium, somatic muscle, nerve cell, retinal cell

2. The capacity for cell division declines with age life span is genetically controlled by mechanism encoded within the cell * embryonic cells can divide up to a total of 50 times * mature cells are capable of fewer division the older they are they less divisions they can make

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CHANGES IN THE CELL:

3. Errors in cell division: error is a deliberate plan of Allah and all is pre-designed with age the following phenomena increase and their cumulative effects lead to ageing or death of the cell: * accumulation of somatic mutation * error rates in protein synthesis * failure of error-correcting mechanism 4. Cellular ageing: ageing, degeneration and eventual death can be explained at the cellular level aging starts with the cell * cellular functions decline gradually with age oxidative phosphorilation, DNA/RNA synthesis, synthesis of proteins and cell receptor * aging cells have definite morphological changes that distinguish them from younger cells

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CHANGES IN THE CELL:

5. The cause of cellular aging: ** endogenous mollecular program of cell senescence

** wear and tear a result damage by: *** free radicals *** post-translational modification of intra-extra cellular proteins *** alterations in the induction of heat-shock prote- ins, *** environmental insults

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CHANGES IN TISSUES AND ORGANS: 1. The cardiovascular system: * arteries become fibrous, sclerosed, less elastic narrowing of arterial lumina increase of both systolic and diastolic blood pressure * the amount of blood pumpued decreases

2. The digestive system: * loss of teeth with age leads to mastication difficulties * poor eating habits lead to nutritional deficiences digestion and absorption are not markedly impaired

3. The nervous system: * amount of nerve cells decrease with age leads to memory impairment + longer response time * psychological impairment more cautious and rigid in be- haviour * could withdraw socially

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CHANGES IN TISSUES AND ORGANS:

4. Skin: * becomes dry and thin loses elasticity, wrinkle develop * patches of dark pigmentation appear * hair becoming gray and thin

5. Endocrine system: * reduced utilization of thyroxine lead s to lower metabolic rate * the sensitivity of the pancreas to insulin is reduced * both androgen and estrogen secretion decrease * the response of cells to endocrine hormones decrease * there is no decrease in pituitary secretions

6. Respiratory system: * vital capacity decrease due to the stiffness of the thoracic cage * the lungs become less elastic

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CHANGES IN TISSUES AND ORGANS:

7. Skeletal system: * loss of calcium in the bones bones more fragile, lighter and break easily * 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 decrease because of arthritis * compression of the vertebral collumn leads to loss of height

8. Urinary system: * the kidney loss mass and efficiency * decreased concentration of urine * decreased renal blood flow

9. Homeostatic mechanism: * remain effec tive but slower in response

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CHANGES IN TISSUES AND ORGANS:

10. Sense organs: * the eye lenses loses elasticity * visual acuity declines and has to be compensated by using glasses and more illumination * weaking of ciliary muscles leads to loss of visual accomodation * some nerve cell and fibres are lost leading to decreased hearing higher tones * reduced taste due to atrophy of taste buds

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CHANGES IN TISSUES AND ORGANS:

11. Striated (skeletal) muscle: * mass lost due to lack of physical activities * muscle metabolic rate decrease * collagen loses its elasticity leads to stiffness

12. Other changes: * all tissues undergo various levels of atrophy * blood vessels lose its elasticity * blood forming stem cells are depleted predisposing the elderly to anemia * amyloid and lipofucsin accumulate in the tissues * impairment of the immune system predisposes the elderly to cancer

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QUALITY OF LIFE IN OLD AGE:

* as people age, the quality of their life deteriorates

* physical activities even in moderation ** reduces morbidity ** protects against neoplasia

* prompt diagnosis and treatment of disease has a positive impact on the quality of life

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SOCIAL ASPECT:

* 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 Mistreatment of parents, ‘uquuq al walidayn, is a major sin if you mistreat someone’s parent someone else may mistreat your parent

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CLINICAL DISORDERS OF OLD AGE:

1. Homeostasis:

** is the state in which the body systems are in perfect harmony and balance a dynamic concept rather than a static one

** If there is disturbance to the homeostatic order the body has corrective mechanism that return it to the previous state almost constantly

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2. Musculo-skeletal dysfunction:

* the elderly have various degree of immobility due to muscular, joint and bone degeneration * the elderly are prone to falling and other incidents because of blurred vision and loss of balance poor proprioception+ vestibular lesions * the elderly like the sick could be exempted from fulfilling all the acts and conditions of the physical acts of ibadat, shalat (sitting down or lying on the side during prayer), shaum (the elderly could be exempted from shaum if it will hurt them) and hajj ( circumbulation or “tawaaf” of the kaaba can be performed on another person’s back or a wheelchair)

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3. Neurological dysfunction:

Functional impairment in many organs occur due to imbalance in the autonomous nervous system: * the elderly may suffer from urinary or fecal incontinence/ retention make them difficult to maintain a state of ritual purity (wudhu) long enoough to complete prayer they are allowed to wear diaper or urinary retainer, make wudhu and pray immediately they do not have to repeat the prayer due to urinary incontinuance * postural hypotension occurs limiting their ability to stand up for prolonged period or to walk * impaired thermoregulation makes them vulnerable to sudden changes in environmental temperature

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4. Psychological dysfunction:

* sleep pattern are altered with insomnia being common * the elderly may suffer various types and degrees of intellectual impairment ao Alzheimer’ disease: cognitive impairment, memory loss (mostly short memory) and reduced or distorted environmental sensory input reduces ability to solve new problems * some elderly are functioning very well intellectually well into their 90s good health or well adapted to their limitation * some elderly 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

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5. Sexual dysfunction:

* old age is a period of declining reproductive ability * sexual function is reduced due to anatomical changes or autonomic dysfunction * reduction of sexual function may not be accompanied by reduction of sexual desire * males may suffer impotence due to erectile difficulties * vaginitis in females is due to deficient estrogens making sexual intercourse painful

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6. Nutrition:

* malnutrition in the elderly are common * the nutritional intake is lower because of poverty, inability to prepare and consume food or just loss of appetite * nutritional deficiences are also common due to unbalanced diets

24GERIATRIC MEDICINE:

* 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 wether diagnostic and therapeutic measures planned will not make the prognosis worse * care must be taken in prescriptions most of the time the elderly needs several medications because of their multiple pathologies beware of drug interaction + altered pharmacokinetics (absorption, metabolism, excretion) * routine screening of the elderly is very useful * rehabilitation is a multi-disciplinary effort involving physicians, nurses, physiotherapists, social workers and psychologists+ fami ly members * home care vs institutional care home care is better because it gives the elderly more feeling of dignity and personal worth

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ISLAMIC GUIDANCE ON THE ELDERLY:

* the elderly has right to be respected“irfan haaq al kabir” * the elderly has legal right of physical support by their offspring * the elderly has right to be treated with extra care * the legal rights and obligations of the elderly may be restricted because of the intellectual impairment some of them remain intellectually competent until the last * the offspring are enjoined to to treat their parent well in their old age” birr al waalidayn” * the offspring must bear patience any annoying demand from their parent

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