I recently had a home visit for one elderly male whom I had advised not to fast during Ramzan because of his medical condition. When I met him again, his blood pressure was stable, his medicines were working, but something else was clearly unsettled. “Doctor sahib, I feel bad,” he said quietly. “Everyone in the house is fasting. I am the only one not fasting.”

Clinically, his condition was straightforward. He had advanced coronary artery disease, long-standing diabetes mellitus and chronic kidney disease. Prolonged fasting in such a patient can precipitate hypoglycaemia, dehydration, electrolyte imbalance, or even cardiac events. From a medical perspective, advising him not to fast was a protective decision.

Yet the real issue that day was not physiological. It was psychological. In medicine, this feeling is often described as illness-related guilt or health-related guilt. It occurs when a person feels they are failing in a religious duty because of a health limitation. In religious contexts, it can also overlap with what psychologists call spiritual distress, a state in which illness interferes with a person’s ability to practice valued spiritual rituals.

For many seniors, Ramzan is not merely a month of fasting. It is identity, routine and continuity with decades of lived faith. A person who has fasted for forty or fifty years does not easily accept the idea that their body can no longer tolerate it. This internal conflict is rarely spoken about openly. Families often focus on medical instructions—“Doctor ne mana kiya hai”—but the emotional side remains unattended. The elderly patient may feel left out of a collective act of devotion taking place within the same household.

In geriatric medicine, we often encounter a similar emotional pattern in patients who lose independence due to illness. The body changes, but the identity of the person does not change at the same speed. An elderly person who has always fasted may still see himself as capable, even when his physiology says otherwise.

Ageing alters several body systems that directly affect fasting tolerance

First, the thirst mechanism weakens with age. Older adults often do not feel thirsty even when the body needs fluids. During long fasting hours, this can lead to dehydration and electrolyte disturbances.

Second, metabolic regulation becomes less stable. Patients with diabetes who take insulin or oral hypoglycaemic drugs risk hypoglycaemia (dangerously low blood sugar) during prolonged fasting. Symptoms such as dizziness, sweating, confusion, or fainting can occur.

Third, many elderly individuals have cardiovascular disease. Conditions such as heart failure, coronary artery disease and arrhythmias may worsen if medications are delayed or fluid balance is disturbed.

Kidney disease is another major concern. Patients with chronic kidney disease (CKD) require stable hydration and electrolyte control. Fasting in such individuals can accelerate renal dysfunction. These are not theoretical risks. They are clinical realities that doctors witness regularly.

Despite this, the psychological burden of not fasting often goes unnoticed. Patients may experience sadness, irritability, withdrawal from family meals, or reduced participation in social gatherings during Ramzan. Some even attempt to fast secretly despite medical advice, which can lead to serious complications.

Addressing this requires both medical explanation and emotional reassurance

One important step is helping patients understand that exemption from fasting is not a failure of devotion. In Islamic jurisprudence, individuals with illness are clearly permitted to refrain from fasting. The principle of preservation of life and health takes precedence.

From a psychological standpoint, reframing the situation helps. Instead of viewing the inability to fast as loss, it can be viewed as a shift in the form of worship.

Ramzan is not defined only by fasting. It is a month of prayer, charity, reflection and compassion. Elderly individuals who cannot fast can still participate fully in these aspects.

Many seniors find comfort in structured alternatives. Regular tilawat (recitation of the Qur’an), extended dua, and participation in taraweeh prayers, where medically possible help maintain a sense of spiritual connection. Acts of charity also play a powerful role. Supporting the needy, arranging meals for those who fast, or contributing to community welfare can create a sense of continued participation in the spirit of Ramzan.

Families also have a role

Emotional inclusion is as important as medical safety. Encouraging seniors to sit with the family during iftar, even if they are not fasting, prevents the feeling of separation.

Healthcare professionals should also be mindful of language. Simply saying “You cannot fast” may feel abrupt to a patient. Explaining the physiological reasons and acknowledging the emotional difficulty often makes the advice more acceptable.

In geriatric care, medicine is not only about controlling blood pressure or sugar levels. It is also about understanding the emotional aspect in which illness exists. The elderly man I visited that day listened as we spoke about these issues. By the end of the conversation, his expression softened. “Doctor sahib,” he said, “perhaps Allah knows my intention.” And that may be the most important point of all.

Ramzan is not meant to break fragile bodies. It is meant to elevate the spirit. Sometimes the most sincere act of devotion is not endurance, but wisdom, recognising the limits of the body and caring for it with gratitude.

© Greater Kashmir