GERIATRICS IN CHINESE MEDICINE

The thinking about geriatrics in Chinese medicine has been dominated by Kidney deficiency for centuries. As Kidney-Jing declines as we age, the clinical approach to the treatment of the elderly has been based largely on tonifying the Kidneys.

However, modern diseases of the elderly that account for 90% of mortality (cancer, heart disease and stroke) are characterized by Fullness. Quite simply, we do not die of Kidney deficiency but of Phlegm, Blood stasis and Internal Wind.

The most common pathogenic factors (and those leading to serious diseases) are:
Phlegm
Blood stasis
Internal Wind

Apart from the major diseases of the elderly such as cancer, stroke and heart disease, very many symptoms and signs that occur in old age are caused by Phlegm and/or Blood stasis. The following is a partial list.

GERIATRIC SYMPTOMS/SIGNS
•Otosclerosis: Phlegm/Blood stasis
•Cataract: Phlegm
•Macular degeneration (vascular, lack of blood nourishment): Blood stasis
•Dry eyes: may be due to Blood stasis
•Alzheimer: Phlegm (the neurofibrillary tangles and plaques in the brain are a form of
Phlegm)
•Parkinson: Wind
•Poor memory: is often due to Phlegm
•Brain muzziness: Phlegm
•Dizziness: Phlegm
•Epiretinal membrane: Phlegm
•Macules: Blood stasis
•Dry skin: in the elderly may be due to Blood stasis
•Itching: Phlegm/Wind
•Numbness: Phlegm/Wind
•Hair loss: may be due to Blood stasis

The following three Tables list the major diseases of the elderly with the pathology they are due to.

PHLEGM - BLOOD STASIS - WIND
Heart disease √ √
Angina √ √
Arteriosclerosis √ √
Thrombosis √
Atheroma √
Hypertension √ √ √

PHLEGM BLOOD STASIS WIND
Stroke √ √ √
Cholesterol √
Chronic bronchitis √
Cancer √ √
Diabetes √ √
Chronic nephritis √

PHLEGM BLOOD STASIS WIND
Prostatic hypertrophy/cancer √ √
Parkinson √
Alzheimer √ √
Trigeminal neuralgia √
Dizziness √ √

Many of the symptoms of the elderly are due to Phlegm:
Heart: mental confusion, feeling of oppression in the chest
Gall-Bladder: stones, nausea, inability to digest fats
Joints: bone deformities, pain, rigidity
Lungs: cough with mucus, feeling of oppression of the chest, asthma, breathlessness
Stomach: lack of appetite, digestive problems, hiatus hernia, acid reflux.
Skin: greasy skin, sweating, yellow moles.

TONGUE DIAGNOSIS IN THE ELDERLY
This has already been discussed in a previous blog (April 2010). The major pathogenic factors of the elderly manifest on the tongue with the following signs:

Phlegm: swollen tongue body, sticky coating
Blood stasis: purple, stiff body
Internal Wind: stiff, moving deviated.

For example, if we see a tongue that is swollen, purple and stiff, it indicates all three pathogenic factors of Phlegm, Blood stasis and internal Wind. When I see a tongue like that in an elderly patient, I actively invigorate Blood and resolve Phlegm for prevention.

TREATMENT PRINCIPLES IN DISEASES OF THE ELDERLY
Considering the above, I believe the most important treatment principles in the elderly are:
1) Invigorate Blood and eliminate stasis
2) Resolve Phlegm
3) Extinguish (internal) Wind

Some people think that eliminating pathogenic factors (with herbal medicine or acupuncture but especially with herbal medicine) may “weaken” the elderly. I have never found that to be true in practice: if an elderly person has Phlegm and Blood stasis, they will not be “weakened” by resolving Phlegm and invigorating Blood. Of course, one does need to adapt one’s doses to age so that dosages of herbs for the elderly should be lower than those for young people.

ON GUILT

For all have sinned and fall short of the glory of God 1 Romans 3.23 In the previous Clinical Tip I discussed sadness and grief deriving from loss as a pervasive emotion in Western patients. In this Clinical Tip, I discuss another common emotional cause of disease in Western patients, i.e. guilt. Guilt is a pervasive emotion in Western patients. It is completely missing from Chinese medicine books and one could say that it simply does not exist in the Chinese psyche. It could be argued that guilt is intrinsically related to the Judeo-Christian religions and especially the Christian religion with its concept of “original sin.” I have never seen expressions referring to “feeling of guilt” as an emotional cause of disease in modern or old Chinese books. It could be argued that this is due to the fact that a feeling of guilt is more or less absent in Eastern societies. In fact, the concept of guilt is totally absent in all three major Chinese religions/philosophies of Confucianism, Daoism and Buddhism. Indeed, Confucius did not even believe in the value of punishment for crimes. Fingarette concurs that the concept of guilt is absent in the Analects of Confucius. The Analects do mention the word chi 耻 in several passages but this is shame rather than guilt. Fingarette says: “If we are unaware of the crucial differences in perspective, these texts on chi lend themselves easily to the assimilation of Confucian shame with Western guilt. Although chi is definitely a moral concept, the moral relation to which it corresponds is that of the person to his status and role as defined by li (rituals). Chi looks outward, not inward. It is not, as is guilt, a matter of the inward state, of repugnance at inner corruption, of self-denigration, of the sense that one is as a person, and independently of one’s public status and repute, mean or reprehensible. The Confucian concept of shame is a genuinely moral concept, but it is oriented to morality as centering in li, traditionally ceremonially defined social comportament [behaviour], rather than to an inner core of one’s being.”2 It should be stressed that what concerns us here in dealing with emotions, is not guilt but the feeling of guilt which is totally unrelated to an actual crime or transgression. For example, a person may have committed a crime but feel no guilt at all; conversely, a person may have committed no crime or transgression but feel guilty (which is usually the case in our patients). Guilt (and shame) are considered by some to be “moral” emotions as they bear upon morality. Wollheim says: “The role of the moral emotions is to provide the person with an attitude, or orientation. What is distinctive of the moral emotions is that the attitude is reflexive. It is an attitude that the person has towards himself/herself as a person.”3 Guilt is strongly linked to a sense of self and specifically to a negative sense of self: this is probably an important reason for the absence of guilt in Chinese culture as the self in Chinese culture is not the individualized, inward-looking, psychological self of Western culture, but a socially-constructed self. This may also account for the presence of shame in Chinese culture (related to a social sense of self) and the absence of guilt (related to an individual self). Guilt can manifest in many different ways, e.g.: – Feeling of responsibility for negative circumstances that have befallen oneself or others – Feeling of regret for real or imagined misdeeds, both past and present – Feeling responsible (and guilty) for any negative thing that occurs to members of one’s family or one’s partner – Taking responsibility for someone else’s misfortune or problem. The above are only a few examples of the sort of behaviour induced by feelings of guilt. A feeling of guilt may be due to the transgression of social or religious taboos or from having done something “wrong” which is later regretted. However, a feeling of guilt may also be innate and not related to any specific action. This innate feeling of guilt derives often from upbringing. This latter feeling is indeed the most destructive one. Guilt is self-reproach for some actual misdeeds or an in-born feeling of guilt totally disconnected from any misdeeds. Guilt includes a sense of inadequacy and despair not found in shame. Guilt does not require any particular offence and the doctrine of Original Sin is an example of this. When assailed by a feeling of guilt, a person is one’s own judge and a more ruthless and less reasonable judge than any real judge. Guilt is inwardly-directed and its object is the self; in this sense, it is almost the “opposite” emotion to that of anger as this latter emotion is usually directed at another person. Guilt is based on a moral criteria of having broken a law of morality (real or imagined). The “mythology” of guilt is the doctrine of the Original Sin. The “authority” providing the criteria is absolute and unquestionable. Guilt is a “dark” emotion with no redemption; it is a much “darker” emotion than shame and in my experience, more difficult to “treat” (if that is the right word). As for disharmonies induced by guilt, this emotion can have different effects in different people. First of all, it may lead to Qi stagnation: it affects any organ and especially the Lungs, Heart, Liver and Kidneys. Due to its “dark”, “stagnating” character, the Qi stagnation may cause Blood stasis easily. This Blood stasis may be in any part of the body and any organ but particularly in the Lungs, Heart, Liver and Kidneys. The pulse is Wiry or Firm. Under certain conditions, guilt may also cause sinking of Qi and affects the Kidneys causing some urinary problems or menstrual problems from sinking of Qi. The tongue has a red tip and possibly purple body. When guilt is the emotional cause of disease, the pulse is Wiry or Firm if there is Qi and Blood stagnation. If there is sinking of Qi of the Kidneys, the pulse is Deep and Weak on the Kidney positions, possibly slightly Overflowing on the Heart position and Choppy in general without wave. How does one “treat” guilt? It is possibly the most difficult to “treat”: it is a ‘dark” and deep-seated emotion and that is probably why it easily gives rise to Blood stasis. I generally choose the points depending on the patterns induced by guilt. I generally treat the Heart, Lungs, Liver and Kidneys. Some examples of points used would be HE-7 Shenmen, P-7 Daling, LU-7 Lieque, LU-3 Tianfu, LIV-3 Taichong, KI-4 Dazhong, KI-9 Zhubin, G.B.-13 Benshen, Du-24 Shenting. Of course, possibly with guilt more than any other emotion, a true healing cannot take place without a conscious effort of introspection from the patient with the help of psychotherapy. 1. Holy Bible, New International Version ®. 1984 International Bible Society. Online version www.biblegateway.com [Accessed 2007]. 2. Fingarette H 1972 Confucius - The Secular as Sacred, Waveland Press, Prospect Heights, Illinois, p. 28. 3. Wollheim R 1999 On the Emotions, Yale University Press, New Haven, p. 148.

THE TONGUE IN THE ELDERLY

Tongue diagnosis plays a very important role in the prevention of disease especially in the elderly. Middle-aged and elderly patients often show abnormal signs on the tongue in the absence of any obvious disease.
Elderly people often suffer from Internal Wind, Blood stasis, Phlegm, Heat or Yin deficiency or a combination of these. For example, it is common to have Blood stasis with Phlegm; or Phlegm with Yin deficiency; or Internal Wind with Phlegm; or a combination of the above. In the elderly, Blood stasis and Phlegm are so common that there is a saying in Chinese medicine which states “In the elderly, when in doubt, invigorate Blood and resolve Phlegm”.
In such cases, the tongue often shows clear signs of these pathogenic factors and it therefore allows us to treat them before they give rise to disease.
In particular, stroke in the elderly usually derives from a complex pathology involving Internal Wind, Yin deficiency with Empty Heat, Phlegm, and Blood stasis. The tongue of the elderly often points to such a complex pathology years before they may get a stroke. Therefore, if I see a tongue with those signs in an elderly person, I take active steps to treat them.
An example of a complex pathology showing on the tongue would be as follows:

- Deviated, Moving, Stiff = Internal Wind
- Red without coating = Yin deficiency with Empty Heat
- Swollen tongue body, sticky coating = Phlegm
- Purple = Blood stasis

The tongue illustrated here is Reddish-Purple (Blood stasis with Heat), Deviated and Stiff (internal Wind), lacking a coating in the centre, Red body (Yin Xu with Empty Heat), Swollen (Phlegm).
The remedy Peaceful Sunset was formulated to treat such a complex pathology in the elderly.