Last week, President Biden tried to acknowledge and mitigate concerns about his capacity to stay on in the most important job in the world. “I know I’m not a young man, to state the obvious,” he said after a disastrous debate against Donald Trump. “I don’t walk as easy as I used to. I don’t speak as smoothly as I used to. I don’t debate as well as I used to.” But, the president went on, “I know, like millions of Americans know, when you get knocked down, you get back up.”
He was asking Americans to see themselves in him and to recognize his debate performance as both an aberration from and a continuation of who he has always been: a person who may suffer and stumble but whose ambition, commitment and confidence in himself have provided a backstop of resilience against insult and injury.
Reporters and Mr. Biden’s biographers have been reflecting over the past week about the severity and nature of his condition and on whether they missed signs or were duped. Americans are suddenly engaged in a speculative conversation about whether the President is physically and mentally fit to lead the country and whether they can trust his self-assessment. What would it mean for a person to “get back up” who also can’t walk, speak or debate with the ease he once did? And how to make sense of his appearance at the debate and the stories that have emerged since about lapses of memory, naps during the day and occasional bouts of confusion?
I’m a geriatrician, a physician whose specialty is the care of older adults. I watched the debate and saw what other viewers saw: a president valiantly trying to stand up for his record and for his nation but who seemed to have declined precipitously since the State of the Union address he gave only a few months earlier.
As a country, we are not having a complete or accurate discussion of age-related debility. I know no specifics — and won’t speculate here — about Mr. Biden’s clinical circumstances. But in the face of so much confused conjecture, I think it’s important to untangle some of the misunderstanding around what age-related decline may portend. Doing so requires understanding a well-characterized but underrecognized concept: clinical frailty.
As we age, everyone accumulates wear and tear, illness and stress. We can all expect to occasionally lose a night’s sleep, struggle with jet lag, catch a virus, trip and fall or experience side effects from medication. But for young and middle-aged people who are not chronically or seriously ill, these types of insults don’t usually change the way we function in the long term. This is not so for frail elders.
“Frailty” is not just a colloquial term; it’s a measurable clinical syndrome, first characterized by the geriatrician and public health expert Dr. Linda Fried, that describes a generalized decrease in physiological resilience to stress, injury and illness.
The field of geriatrics recognizes a number of conditions that are not diseases, per se, but signify how an aging body might become vulnerable, out of equilibrium and unable to overcome difficulty. These conditions result from the familiar hardships of age — declining vision and hearing, weakening muscles, brittle bones, brains that have suffered silent strokes, hardened arteries and the stress on hardworking organs that even a lifetime of healthy habits cannot entirely prevent.
Frailty is the most important, all-encompassing geriatric syndrome: It’s the framework we use to describe what others sometimes understand as the accumulating burdens of old age. Not everyone who is old is frail, and not everyone who is frail is old, but frailty is exceedingly common as people get older (it affects as many as a quarter of people who are over 85), and it often precedes serious debility and decline.
Much of the confusion surrounding Mr. Biden’s debate performance stems from his being described as having good days and bad days, rather than a more consistent level of functioning. These reports have been met with speculation and skepticism: Is he really ever doing all that well if, as reporting suggests, there have been multiple incidents of cognitive lapses that seem to be growing more frequent? Mustn’t this suggest some sort of cover-up about his condition?
Without knowing the specifics of the president’s health issues, I say: perhaps but not necessarily. A shifting ratio of good days and bad days is often how clinical frailty appears. The pattern of decline in frailty is a gradual dwindling of a person’s health, a line sloping slowly downward.
Dr. Patricia Cantley has written about a useful analogy that she offers to frail patients and their loved ones to explain what’s going on: A beautiful, skillfully assembled paper boat sailing on a pond may look great and sail without difficulty, as long as the water is calm and the sun is shining; but should a gust of wind or a wave come up unexpectedly, the paper boat is vulnerable to damage, may tip over easily and is unlikely to be righted and sail as well as before.
For frail elders, a gust of wind may be a cold or the side effects from taking cold medication. Or a bout of depression brought on by the grief and loss that is also an inherent feature of getting older or a stumble leading to a broken hip. Frailty can best be prevented and managed through assiduous self-care — exercise, sleep, a healthy diet to maintain one’s weight, careful management of medical conditions and ongoing, fulfilling relationships to stave off loneliness. But to a large extent, these are all harm-reduction efforts. Time marches forward, bodies decline, and the growing expectation that we might all live in perfect health until our 100th birthdays reflects a culture that overprizes longevity to the point of delusion.
Getting older often means accumulated wisdom, experience and even happiness, but it also means slowing down. Ours is a culture that greatly undervalues the potential contributions of older people who have so much to offer in terms of care, mentorship and experience and instead consistently portrays them as burdensome. To recognize that people are frail is not to think of them as no longer productive, dignified or wholly intact. It does not mean they are necessarily significantly cognitive impaired, nor does it mean they are imminently dying.
Elders who live successfully with frailty have transitioned into a phase of life in which they no longer expect and should not be expected to function in the exact same ways they’ve always functioned. It may mean changing one’s habits and routines to accommodate a slower-paced, less volatile life, accepting with grace both the privileges and the constraints of age.
