Clinical, Sociological and Cultural Dimensions of Frailty: A Dialogue

Posted on: 4 December 2023 by Professor Susan Pickard in Blog

A group photo of Centre for Ageing and the Life Course members.

This three-day symposium, hosted by the Brocher Foundation, Switzerland, brought together scholars in ageing from a number of disciplinary perspectives, including medicine, social science, arts and humanities, to discuss the contested concept of frailty.

We were motivated by the desire to bring the methodologies and perspectives of sociology, psychology, philosophy, social anthropology and literary gerontology, as well as those with lived experience as carers, to bear on the biomedical approach in order to facilitate clinical interactions with older people and deepen clinicians’ understanding of both lived experience and the social structures that underpin frailty. We wanted also to bring theory and practice into closer dialogue. However, the intention was not to synthesise or smooth away the differences between (and within) approaches associated with different disciplinary standpoints but rather to highlight how these differences can potentially both enrich each other and broaden our individual perspectives to shape a more nuanced and multi-faceted understanding of frailty. In other words, we aimed to pose questions and seek (and sometimes find) answers together which may not have been possible separately.

Accordingly, the symposium was organised around four themes intended to stimulate more focused cross-disciplinary discussions. These were: (i) turning the gaze on ‘frailty’ as a concept and technology; (ii) unequal ageing, relationships of power and frailty; (iii) social and philosophical concepts and methodologies; (iv) representations and alternative representations and imaginaries of frailty and deep old age. We organised our discussions around four broad themes comprising presentations followed by a group discussion. We also watched a movie together as a group and discussed the themes arising.

Theme One: Turning the Gaze on ‘Frailty’ as a Concept and Technology

Overarching questions that framed this theme included: what understandings of the older body do the new technologies of frailty introduce and replace? How are these framed in medicine, public health, biology and biogerontology? How are they changing and evolving? What is the relationship between new technologies and broader cultural attitudes towards ageing? Interestingly, all focused on Covid as both having increased the importance of frailty technologies and clarified its purpose and utility. Presentations involving both literature searches and reflections on empirical practice highlighted that Covid served as a key conjuncture in terms of positioning frailty at the centre of the field of biological and clinical ageing, including clinical practice. We also learned how the application of the Clinical Frailty Scale during the pandemic brought with it certain consequences including both a reduction in complexity and its implementation as a rationing practice. Where frailty served as the ‘gateway’ to the fourth age, it was evident here as a technology of biopower that served to divide frail older people from the rest of the patients. We also explored further the link between the lab and the clinic, with the social and the biological entangled in the concepts of epigenetic clocks and the notion of inflammageing, among others. With Switzerland as an example, we learnt how inequality is further implicated in the advent of personalised health targeted at avoiding these developments.  

Theme Two: Unequal Ageing, Relationships of Power and Frailty

This theme placed power and inequalities at the heart of the category of frailty. It explored how clinical frailty reflects a deeper and more long-lasting social frailty, powerlessness and vulnerability and how the clinical and the social can be brought closer together in both care and cure. Inequalities of gender, poverty and race all increase the chances of becoming frail as does (lifelong) sexism, racism and the stress of poor life chances, unemployment and poor housing. How might we turn frailty into a discussion about our social responsibility for others? This theme explored ethnicity and frailty in lived experience, in encounters with emergency admissions in the clinic, and through the unique standpoint of being both a doctor and a carer. Several key principles that emerged from both the presentations and the discussions included the importance of: listening to the voices of the older people and the carers themselves; recognising frailty as relational where carers also are involved in strategies for resilience and in preserving the ‘balance’ that is at the heart of both frailty and healthy ageing; being attuned to cultural difference (between as well as within cultures); using inclusive methodologies and theories, such as intersectionality and photovoice/digital story-telling alongside biographical narrative interviews as a means of capturing unique life stories that can pinpoint the unique combinations of both deficits and strengths. In terms of the utility of these insights, this could enable us to unpick the heterogeneity that exists for people within the same ‘frailty score’. For busy practitioners, it is a reminder of the importance of avoiding reifying the label ‘frailty’ where, helpful and indeed necessary in some situations as it is, labels are imposed upon an underlying complexity and may be a means of separation from that complexity to the detriment of holistic interventions. We also discussed wider considerations including the limits of the clinic in solving social and existential problems and indeed the way the complexity and lack of integration of care itself could impact on outcomes for older frail patients.

Theme Three: Social and Philosophical Concepts, Methodologies, and Theories

This theme was framed by the following questions:  what does frailty tell us about our views of the ‘civilised body’ in late modernity? How can ageing into deep old age be seen in terms other than failure? Can resilience and frailty co-exist? Alternatively, how might we reclaim terms such as abjection or dependence and reconfigure them according to different ethics and life course values? Presentations and discussions highlighted how resilience and frailty can and do co-exist in various complex ways. Whilst interventions can increase resilience these need to be broad as existential and social issues shape these, both connected to the current life stage (such as loneliness and depression) and to issues and inequalities throughout the life course (for example, poor education) which underpin the loss or lowering of resilience. However, we also asked: is frailty universally negative? Empirical evidence from interviews with older people suggested that frailty can bring a rich meaning existentially allowing for growth even as it may involve existential ‘separation’ from others. A more negative connection is between frailty and what has been called the ‘fourth age’, a depiction of ‘unwanted’ old age (rather than ‘successful ageing’ for instance) that exists as a nightmarish vision of decrepitude, extreme senescence and senility. Whilst separating the frail from the rest, and thus increasing the social and existential loneliness of ageing, it serves some positive purposes both in enabling old age per se to be disentangled from a wholly negative depiction and also as a means by which healthier older people can separate themselves from thoughts of death and limits. A lively debate ensued, and was not resolved, as to the mutability of the social imaginary and the degree to which this could be shifted to something more positive.

Theme Four: Imaginaries and Alternative Imaginaries of the Fourth Age

This theme was framed by the questions: How do representations shape the way we view social problems, and construct social policy, affecting older people from the recent Covid-19 pandemic, to austerity and political change? How might we draw from alternative conceptions of deep old age in different cultural traditions beyond the west as well as through both historical and innovative contemporary approaches within the west? To help us address these questions, we considered images of ageing associated with feminist philosophy and archetypal theory, depictions of ageing in Japan and changing representations of nursing homes in literature and movies over the past fifty years. First, we discussed the particularly gendered nature of the fourth age. The figure of the hag or crone has a particularly powerful symbolic association with senescence yet this figure has been reclaimed by feminist philosophy to signify positive associations of wisdom in the face of finitude which in turn helps re-vision ageing from signs of decline to sign of power. The implication is that anti-ageing is both anti-death and ultimately anti-life because it denies what it is to be human, including acquiescence in the cycle of change, growth, decline and death and acknowledgement of limits. A presentation on ageing in Japan suggested elements of an alternative aesthetic sensibility in which loss co-exists with gain and in which the journey to and through frailty can be seen in terms of ‘meaningful decline’. Meanwhile, socio-cultural change in terms of the imaginative representation of the fourth age in ‘nursing home’ movies/novels in the west suggested the emergence of a more positive valuing of frailty. Although representations are not mimetic they do shape public discourse as well as well as private ideas of what is possible and suggest emerging structures of feeling alternative to the ‘fourth age’ social imaginary we noted in the previous section. We returned again to the question that we had picked up in the last session, namely whether this could shift the ‘glacial’ or deep settled magma of the fourth age imaginary but some (not all) of us were hopeful! Even the hopeful among us had to also acknowledge the currents that countered this, including, as we had seen earlier, the new centrality of frailty (through scores and scales) as a practice in clinical medicine and the increasing techniques in personalised medicine to distance the more privileged from age altogether. However, the ability of the imagination to capture the beauty in frailty (and dementia) remained equally as powerful currents perhaps: those poets, film makers and artists able, despite the many unwelcome corporeal and social aspects of deep old age, to yet grasp the value of this life stage, to see it as a ‘gateway’ not just to the fourth age but to a meaningful existential experience and to inspire love and care in others. 

The symposium was organised by Professor Susan Pickard (Centre for Ageing and the Life Course, University of Liverpool) and Dr Victoria Cluley (University of Nottingham and Centre for Ageing and the Life Course), and included: Professor Jay Banerjee (University of Leicester); Professor Bev Clack (Oxford Brookes University); Dr Jason Danely (Oxford Brookes University); Dr Chao Fang (Centre for Ageing and the Life Course, University of Liverpool); Professor Paul Higgs (University College, London); Professor Carol Holland (University of Lancaster); Professor Ulla Kriebernegg (University of Graz); Professor Tiago Moreira (University of Durham); Professor Des O’Neill (Trinity College, Dublin); Dr Shibley Rahman (University College London); Dr Louise Tomkow (University of Manchester). 

 

Find out more