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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0004-AGE-RELATED CONDITIONS

Background reading material for medicine & fiqh panel held on 22nd April 2000 at the Kulliyah of Medicine, International Islamic University, Kuantan, MALAYSIA by Professor Omar Hasan Kasule sr.

OUTLINE

14.4.1 PREGNANCY & AND DELIVERY

Intra-Uterine Disease

B.  Intra-Partum Conditions

C. The New-Born

D. Nutrition & Breast-Feeding             

Maternal Condition

 

14.4.2 INFANCY

Congenital Anomalies

B. Infections

C. Trauma

Neoplasms

E. Child Care

 

14.4.3 CHILDHOOD

A. Disorders Of Growth And Development

B. Ibadat

C. Family:

D. Muamalat:

E. Jinayaat:

 

14.4.4 ADOLESCENCE AND YOUTH

A. Adolescent Growth Spurt

Health Problems

C. Behavioral Problems

D. Violence

E. Sexual Problems

 

14.4.5 OLD AGE

A. Concepts

B. Musculo-Skeletal Motor Dysfunction

C. Neurological Dysfunction

D. Psycho-Social Dysfunction

E. Others

 

14.4.1 PREGNANCY & AND DELIVERY

INTRA-UTERINE DISEASE

DIAGNOSIS AND TREATMENT

Pre-natal diagnosis (amniocentesis, CAT scan, sonar) can settle disputes about paternity. It is also possible to diagnose some diseases in advance.

The pregnant woman has certain rights (KS 547)

 

ASSESSMENT OF FETAL MATURITY

Decisions on pregnancy termination based on assessment of fetal maturity

 

B. INTRA-PARTUM CONDITIONS

Dystocia and interventions

Ecclampsia

 

C. THE NEW-BORN

Adhan and iqamat for the new-born:

Naming: problem of choosing names in cases of indeterminate gender

Aqiiqa for the new-born:

Circumcision: infants with hemostatic diseases may bleed on circumcision

Screening for metabolic & genetic disorders: discovery of  diseases early may enable earlier treatment.

Immunization:

 

D. NUTRITION & BREAST-FEEDING                    

Mandatory breast-feeding for 2 years

Breast-feeding by a wet-nurse

Legality of milk banks

Payment to divorced woman to breast-feed baby

 

MATERNAL CONDITION

Hemorrhage

Infection

Post-natal exhaustion

Post-natal depression

 

14.4.2 INFANCY

CONGENITAL ANOMALIES

TYPES OF ANOMALIES

GIT anomalies: Esophageal atresia, duodenal obstruction, jejunal/ileal obstruction, meconium ileus, meconium plug, colonic atresia, Hirschprung's diseaseomphalocele, gatsroschisis, diaphragmatic hernia, aganglionic megacolon, imperforate anus, pyloric stenosis, intususception, Merkel's diverticulum, intestinal duplication, intenstinal polyps

 

GUT anomalies: undescended testis

SURGICAL TREATMENT

Consent to surgical treatment. Long-term consequences

 

MEDICAL TREATMENT

 

B. INFECTIONS

 

C. TRAUMA

 

NEOPLASMS

Wilms' tumor, neuroblastoma, teratoma.

 

E. CHILD CARE

NAFAQAT

The father is responsible for nafaqat. The nafaqat is paid during marriage and also after divorce. Financial maintenance of single poor mother.

 

NEGLECT AND ABUSE

Definition of neglect

Definition of abuse.

Types of abuse: physical, sexual, and psychological

 

IMMUNIZATIONS

Vaccination against small-pox, chicken pox, measles, and mumps. Advantages and side-effects. Is taking a child for immunization waajib or manduub?

 

14.4.3 CHILDHOOD

A. DISORDERS OF GROWTH and DEVELOPMENT

DEFINITION & CLASSIFICATION

classification by level/site of occurrence.  gene anomalies( mutations) - chromosomal anomalies(aneuploidy, translocations, deletion, duplication) - neoplastic cell growth ( oncogene & suppressor genes, initiation & promotion) - tissue or organ - functional. classification by time of occurrence: congenital - postnatal

 

CAUSES

Hormonal causes: deficiency and excess; nutritional causes: protein energy malnutrition and miasmas; congenital and chromosomal, environmental, multiple inheritance, metabolic /nutritional

 

MANIFESTATIONS

Abortion, fatal death, physical handicap, physiological anomaly, mental handicap,

Slow growth, rapid growth, and malformations

 

LEGAL AND ETHICAL ISSUES

Growth hormone for slow grower, delayed menarche and legal obligation, precocious growth & sexual maturation, genetic engineering, surgery for cosmetic reasons

 

B. IBADAT

The teaching of the prophet is that children should be ordered to pray at the age of 7 and punished for missing prayer at the age of 10. Consideration may be made in these ages depending on whether the children are fast-growers or are slow-growers.

 

C. AADAAT:

Children who are precocious growers need more food.

 

D. FAMILY:

Children especially females who are precocious growers should cover their awrat and observe the etiquettes of adult hijab earlier than normal because of earlier sexual maturation. Care should be taken not to marry off children growing quickly because their cognitive and emotional development may lag behind their physical growth.

 

E. MUAMALAT:

Children who grow rapidly could be allowed to undertake some transactions if their cognitive skills are judged to be like those of adults.

 

F. JINAYAAT:

Rapidly growing children may be tried and they may give evidence as adults. Slower-growing children may not be treated as adults even if they reach the age of 15 years.

 

14.4.4 ADOLESCENCE AND YOUTH

A. ADOLESCENT GROWTH SPURT

Early and delayed puberty

 

HEALTH PROBLEMS

 

C. BEHAVIORAL PROBLEMS

Adolescents acquire abstract thinking but they have little wisdom and experience with the result that they make many mistakes. They are confused about their identity, are they children or are they adults? They resent parental control yet they cannot live independently on their own. They are prone to addictions.

 

D. VIOLENCE

Causes of violence

Effects of violence

Prevention of violence

 

E. SEXUAL PROBLEMS

The adolescents are biologically mature and feel that they can have sex. They however do not have the emotional and cognitive maturity needed for healthy sexual relations. They are not able to control their sexual instinct. They are influenced by the media and the popular culture that teach sexual permissibility. The need for professional and career preparation results in delay of marriage.

 

14.4.5 OLD AGE

A. CONCEPTS

THE CONCEPT OF HOEMOSTENOSIS:

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.

 

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, 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.

 

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 (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).

 

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.

 

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.

 

ISLAMIC GUIDANCE ON THE ELDERLY:

Rights of the elderly: irfan haqq al kabir (KS 68). The elderly have a legal right of physical support by their offspring (KS 576)

 

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 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 institutionalisation. Home care would be the best because it gives the elderly more feeling of dignity and personal worth.

 

MUSCULO-SKELETAL MOTOR DYSFUNCTION

The Qur'an describes old age as the age of weak bones (19:4). 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). 

 

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)

 

In sickness permission is given to omit circumbulation 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

.

C. NEUROLOGICAL DYSFUNCTION

Autonomic dyfunction: 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.

 

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.

 

D. PSYCHO-SOCIAL DYSFUNCTION

SLEEP DISORDERS:

The sleep patterns are altered with insomnia being common. The elderly cannot sleep in the early hours of the morning probably due to depression.

 

MENTAL IMPAIRMENTS:

Description of 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.

 

Ibadat:The elderly may not be able to fulfil 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

 

Muamalaat: restriction on the elderly in transactions

 

Jinayaat: reliability of evidence of the elderly. Criminal liability for actions.

 

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 actualisation, 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 (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. In old age males may suffer from impotence due to erectile difficulties. Vaginitis in females due to deficient estrogens making sexual intercourse painful.

 

E. OTHERS

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.

 

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 (KS 334).

 

DISCUSSION

PREGNANCY and DELIVERY

Rulings on pre-natal diagnosis

Naming of newborns with indeterminate gender

Circumcision of newborns with bleeding disorders

Neo-natal screening for genetic and metabolic disorders

Rulings on milk banks

 

INFANCY

Formula for computation of the level of nafaqat

Rulings on child abuse: physical, psychological, and sexual

Rulings on obligation of immunization

 

CHILDHOOD

Rulings on use of hormones for slow growers

Legal obligations for pubertal signs delayed beyond the age of 15

Rulings on legal obligations for children with precocious growth

Rulings on minimum age at marriage for children growing precociously

Ruling on transactions by children below the age of majority

Court trial of quick-growing children as adults

 

ADOLESCENCE

1. Rulings on sex education for adolescents

 

OLD AGE

Abuse of the elderly

Ruling on offspring to provide physical support for the parents

Salat, hajj, and jihad obligations for the elderly

Wudhu and salat with fecal and urinary incontinence

Court testimony by the elderly ? memory loss

Professor Omar Hasan Kasule April 2000