Home

ISLAMIC MEDICAL EDUCATION RESOURCES-03

0102-AGE-RELATED CONDITIONS

Lecture for 3rd year medical students on 3rd February 2001 by Professor Omar Hasan Kasule Sr.

A. PREGNANCY & AND DELIVERY

INTRA-UTERINE DISEASE

Diagnosis and treatment: Pre-natal diagnosis (amniocentesis, CAT scan, sonar) can diagnose some diseases in advance so that treatment plans can be made before birth. On the other hand, it may open the door to the possibility of criminal abortion of malformed or sick fetii. Pre-natal diagnosis could be prohibited under the principle of closing the door to evil, sadd al dhari’at, because of its association with abortion. The pregnant woman has certain rights (KS 547). In the light of Law her interests come before those of the fetus thus maternal disease in pregnancy will be treated even if that causes a risk such as early termination. When a husband dies, prenatal examination will help settle the issue whether the fetus was alive at the time of the father’s death. This determination has serious legal consequences. If the fetus was alive it can inherit from its father and even if it dies in utero after that, its inheritors can get its inheritance.

 

Assessment of fetal maturity: Decisions on pregnancy termination are based on assessment of fetal maturity. If a fetus is mature and can be delivered safely, induction of labor can be started. This becomes crucial in cases of maternal disease like ecclampsia that require delivery as soon as possible.

 

INTRA-PARTUM CONDITIONS

Dystocia and interventions: In difficult labor, contradictions in the purposes and principles of the law can arise because there are two lives to consider, the mother and the fetus. Early medical and surgical intervention in the birthing process is generally for the benefit, maslahat, of the mother but could be detrimental, dharar, to the pre-mature fetus. In some cases like those of ecclampsia, early delivery is more to the benefit of the mother but delay of delivery could eventually be harmful to the fetus as well. The principle of necessity, dharuurat, is invoked in situations of respiratory distress when delivery must be effected as early as possible to prevent further deterioration in the fetus.

 

THE NEWBORN

Adhan and iqamat are required for the newborn. A name should be chosen as soon as possible. A problem could arise in cases of indeterminate gender. The ‘aqiiqah ceremony for the newborn is a social occasion for introducing the baby as a new member of the community. Uncontrollable bleeding may complicate circumcision of newborns with hemostatic diseases. Screening newborns for metabolic & genetic disorders is encouraged since it leads to discovery of diseases early to enable earlier treatment. Newborn Immunization is encouraged because it prevents disease.

 

NUTRITION & BREAST-FEEDING            

Breast-feeding is mandatory for 2 years according to Qur’anic injunction. Breast-feeding by a wet-nurse is allowed. Milk banks are discouraged because they may create unregistered foster relations that invalidate marriage later in life. Payments are made to a divorced mother for breast-feeding the baby.

 

MATERNAL CONDITIONS

Post-partum hemorrhage has the same legal rulings as menstruation. Post-natal exhaustion may necessitate delay of physical activity. Post-natal depression may constitute deficient legal competence for making treatment decisions for the mother and baby.

 

B. INFANCY

CONDITIONS OF INFANCY

Congenital anomalies, infections, and trauma are common neonatal conditions. The common GIT congenital anomalies are esophageal atresia, duodenal obstruction, jejunal/ileal obstruction, meconium ileus, meconium plug, colonic atresia, Hirschprung's disease, omphalocele, gastroschisis, diaphragmatic hernia, aganglionic megacolon, imperforate anus, pyloric stenosis, intussusceptions, Merkel's diverticulum, intestinal duplication, and intestinal polyps. The common GUT congenital anomalies are undescended or underdeveloped testes. Consent to surgical treatment by parents must consider long-term consequences and must follow the principle of the Law that preventing harm has priority over getting a benefit. Neonatal infections occur during the peri-natal period and may have long-term sequelae if not treated vigorously. Birth trauma is sustained in dystocia. Neoplams are rare in neonates. The most common ones are Wilms' tumor, neuroblastoma, and various types of teratoma.

 

CHILD CARE

Nafaqat: nafaqat includes all material sustenance needed for the infant such as food, clothing, and medical care. The father is responsible for nafaqat during marriage and also after divorce. The extended family and the state are responsible for financial maintenance of single poor mothers.

 

Neglect and abuse: Neglect and abuse can be defined in various ways. The definitions change with time. Child abuse can be physical, sexual, or psychological.

 

Immunizations: According to the purpose of preserving life, taking an infant for immunization is waajib. Vaccination is usually against smallpox, chicken pox, measles, and mumps. The risk of vaccination reactions is small compared to the advantages of the procedure.

 

C. CHILDHOOD

DISORDERS OF GROWTH and DEVELOPMENT

Definition & classification: The disorders can be classified as genetic or non-genetic. The genetic consist of gene anomalies (mutations), chromosomal anomalies (aneuploidy, translocations, deletion, duplication). Neoplastic cell growth is triggered by failure in regulation of oncogene and suppressor genes affecting either initiation or promotion. Non-genetic disorders may be anatomical or functional. They are classified by tissue or organ affected. They may also be classified by time of occurrence: congenital, perinatal, or postnatal.

 

Causes: Hormonal causes (deficiency and excess); nutritional causes (protein energy malnutrition and marasmus); congenital and chromosomal; environmental; multiple inheritance; and metabolic.

 

Manifestations: Abortion, fatal death, physical handicap, physiological anomaly, mental handicap, Slow growth, rapid growth, and malformations.

 

Legal and ethical issues: Growth hormone treatment for slow growing children does not raise an ethical issue of changing Allah’s fitra. The children have an anomaly that has to be removed as much as possible under the principle of injury, dharar. Delayed menarche may delay adulthood and legal obligation. Generally reaching the age of 15 years indicates maturity even if sexual maturation is not complete. The rules of hijaab and male-female interaction will have to be applied earlier in cases of precocious growth to avoid any transgression. Precocious growth does not imply sexual maturation so care must be taken not to marry off young girls. If possible considerations of cosmetic surgery should be delayed until the children each the age of consent. For urgent measures the parents can consent on behalf of the children.

 

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.

 

‘Aadaat: Children who are precocious growers need more food.

 

Munakahaat: 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.

 

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

 

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.

 

D. ADOLESCENCE AND YOUTH

The adolescent growth spurt causes health problems as the body structure and physiology adjust to increased demands. Adolescents develop several behavioral problems as they  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. Violence is common in adolescents. They also indulge in sexual illegal pre-marital activities. 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. The media and the popular culture that teach sexual permissibility influence them. The need for professional and career preparation results in delay of marriage. Adolescent and youth behavioral problems are best resolved by preventive tarbiyyat. Intervention when they are already grown up is sometimes too late.

 

E. OLD AGE

CONCEPTS

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

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.

 

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). 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.

 

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.

 

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. Muamalaat: restriction on the elderly in transactions. Jinayaat: reliability of evidence of the elderly. Criminal liability for actions. Psychosocial: 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 (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.

 

 

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).

Professor Omar Hasan Kasule Sr. February 2001