Frailty as illness and the cultural landscape

IN SEARCH OF FRAILTY

It is over 30 years since Susan Sontag famously denounced the use of illness as metaphor.¹ Her work examined the dangers of the use of language we adopt in describing cancer, tuberculosis, and AIDs. Since the publication of her essay, the way we look after our patients has radically changed. We live in the age of frailty. First described as a clinical syndrome (or ‘phenotype’) in 2001,² its definition remains loose and variable even among the medical profession. A recent summary of NICE guidance on multimorbidity in the BMJ suggests we consider frailty as a symptom complex.³ The challenges of looking after an ageing population living with multiple conditions are clear. Only when remembering what Sontag tells us about how we talk about diseases might we realise that the complexity of frailty is perhaps more than we bargained for.

In West Wales we certainly have our challenges in caring for people who are frail and widely dispersed by the rural landscape. The people who live in our community have a strong sense of connection to the land and traditions of farming. The attachment is so strong that it is fairly usual for you to find the patient you are visiting out in the cowshed, even if they are in their eighth or ninth decade. The stoicism of my patients got me thinking that perhaps the idea of frailty as illness needed closer attention.

Just as Sontag did in the 1970s, it is in the cultural landscape that we can look for reference points. This may help us better understand the implications of saying that our patients are frail. In doing so I could not help but immediately trip over Shakespeare’s Hamlet.⁴ In disgust at his mother’s marriage to Claudius after the death of his father, Hamlet declares: ‘Woman thy name is frailty.’

The implication of this short phrase is heavy with dangerous metaphorical meaning and goes to the very heart of what feminism has been combating for the last 100 years. Although these words are now over 400 years old they still inform our ideas of how frailty may be perceived as dependency, defeat, and even subjugation.

Shakespeare can then open the door for us on frailty in art. Although we might believe frailty to be a syndrome that increases the risk of hospital admission, falls, and death, many artists across varying mediums struggle with the wider idea of frailty as part of the human condition. The paintings of Lucian Freud examine the human body in a way that insists we look with a piercing gaze at ugliness and imperfection. He examines the frailty that we all might be trying to hide. This idea might be helpfully compared with Sontag’s exposure of the myth that cancer was in some way linked to weakness in character. Frailty may therefore be regarded as a weakness of appearance and a disease that is about the way we look. It follows that perhaps it may be a condition that patients might seek to conceal.

Picture by Howard Barlow. POET — RS THOMAS at his home on the LLYN PENINSULA. September 1997.

With Freud in mind, we can then begin to identify the common cause of most artists wrestling with the idea of singular human frailty. However, it is in one of Phillip Larkin’s most famous poems that the notion of collective or national frailty is characterised. In The Whitsun Weddings⁵ he evokes postwar Britain in the baby boomers’ era. The couples he finds himself travelling with on a train are getting married in a hot 1950s summer and he describes a:

‘… frail

travelling coincidence; and what is held

Stood ready to be loosed with all the power

That being changed can give.’

Larkin is saying that we are collectively changed by war and weaker. We are heading for the unknown in our collective frailty, and in re-reading this poem today we are wiser about the reality of where we have arrived. It is in this very generation that frailty syndrome has become prevalent.

One of Larkin’s 20th-century poetic contemporaries looms in the shadows of literature as the self-styled ‘Ogre of Wales’. RS Thomas’s early poetry also confronts the idea of national frailty with an excoriating examination of rural welsh life. This is laid bare in his poem ‘Welsh History’:⁶

‘… The hills

Were no harder, the thin grass

Clothed them more warmly than the coarse

Shirts our small bones.

… our lean bellies

… were a proof

Of our ineptitude for life’

RS THOMAS AND THE ROLLING STONES

Some of the physical characteristics of frailty and its association with poverty (and even stupidity) are recognisable to us in this poem and reinforce the idea of an association with weakness or failure. Furthermore, much of RS Thomas’s work examines the component parts of frailty and ageing in some detail. His later poems reference the loss of his wife in old age, confronting his doubt in religion, and in one particular poem he denounces the medical triumphalism of the eponymous condition of Alzheimer’s disease. However, it is his own photographic portrait, taken near the end of his life, that tells us not about weakness but the power of frailty. He is clearly physically frail but at this moment he was also, through his writing, formidable, forceful, and irrepressible. As a reminder of this enduring possibility I keep a photo of him in my consulting room (see left).

RS Thomas died in September 2000 at the age of 87 years. Leap forward to July 2013 and a sweltering hot day in central London and the Rolling Stones are playing Hyde Park. A homecoming gig of sorts, reviving the now legendary 1969 concert at the same venue. The four core members of the band came on stage with a combined age of over 250 years and were playing to a crowd of 65 000. I was lucky enough to be one of them. It was Keith Richards who opened the show, swinging his right arm through the air while his left hand — wracked with osteoarthrosis — gripped the neck of his guitar for the opening chords of ‘Start Me Up’. Bowel cancer survivor and drummer Charlie Watts is famous for saying that touring with the Rolling Stones was 5 years of playing and 25 years of hanging around, which always resonated with me as a hospital-based medical student. The Rolling Stones are now older and developing some of the physical characteristics we might associate with frailty. Yet they remain ‘too tough to die’ and defy the stereotype of ageing, reminding us of their ongoing relevance to the present. Now he is past his 70th birthday it is difficult to imagine that Keith Richards would benefit from an advanced care plan.

So, frailty might mean weakness or failure but perhaps with characters such as the Stones on the scene it can still mean defiance and power. These qualities are ones I have observed in practice nearly every day in patients who fit the ‘frailty syndrome’ diagnostic definition. However, defiance is not universal, and to illustrate this it is perhaps helpful to look at a fictional character from the 2007 film adaptation of Cormac McCarthy’s novel No Country for Old Men. Sheriff Ed Tom Bell is the ‘law man’ in a dusty Texas county in the 1980s. He struggles to keep up with the violent and destructive trail left by battling factions in a cocaine deal ‘gone bad’. He reflects on the past and his inability to change or accept the exponential rise in brutal crime around him. He has a quiet acceptance and sadness that his time is passing, illustrated in a section of dialogue where he describes a dream about his father: ‘... it was like we was both back in older times and I was on horseback goin’ through the mountains … It was cold and there was snow on the ground and he rode past me and kept on goin’. Never said nothin’ goin’ by. He just rode on past … And in the dream I knew that he was goin’ on ahead and he was fixin’ to make a fire somewhere out there in all that dark and all that cold, and I knew that whenever I got there he would be there. And then I woke up …’

Although Texas is a long way from Carmarthenshire we can still find parallels between Ed’s viewpoint and our own patients. When we are failing in our power we begin to reflect and measure our contribution against the yardstick of previous generations.

DO NOT GO GENTLE

The conclusion to my own thinking on frailty led me back to my own place of practice. In West Carmarthenshire, we have a branch surgery in Laugharne only a short distance from the boathouse where Dylan Thomas penned some of his most famous poetry. One of those poems, well known to many as a message to his dying father, resonates with our idea of how human beings regard frailty at the end of life. Even when we are at our most frail and aged, when there is no modern medicine to help us, when there is no benefit in being in a hospital, we still may choose to: ‘... not go gentle … rage, rage against the dying of the light.’

On this short tour, perhaps we now have more questions than answers about what frailty might really mean. The following lines from Dostoyevsky’s Crime and Punishment⁷ may be helpful in reminding us to continue to look around before we make any assumptions about frailty: ‘... you, a doctor, whose duty first and foremost is to study man and who has more opportunities than anyone else to study human nature, can you not see from all these facts, what kind of nature we have here …?’