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Frailty and the Foolishness of Eos

¹ Longitudinal Studies Section, Clinical Research Branch, National Institute on Aging, Baltimore, Maryland.
² Harbor Hospital, Medstar, Baltimore, Maryland.

Address correspondence to Luigi Ferrucci, MD, PhD, Longitudinal Studies Section, Clinical Research Branch, NIA-ASTRA Unit–Harbor Hospital, 5th Floor, 3001 S. Hanover St., NM540, Baltimore, MD 21225. E-mail: ferruccilu{at}grc.nia.nih.gov

DESPITE thousands of pages in the geriatric literature dedicated to the concept of frailty, its definition remains elusive. In the land of frailty, confusion, contradiction, and ambiguity reign supreme. Yet, understanding the pathways to and consequences of frailty continues to be a fundamental aspiration of many geriatricians and researchers in the aging field. Targeted attempts to clearly define the essence of frailty and develop a widely accepted operational definition have often reduced creative and imaginative scientists to skeptical people, fond of rational criteria, regulations, policies, and conventions. What is it about frailty that so profoundly tears at the core of our geriatric soul? In this issue of the Journal, Karen Bandeen-Roche provides evidence that the operational criteria for the frailty definition developed from the Cardiovascular Health Study behave like a medical syndrome (1). This article is a solid step toward translating the concept of frailty into a clinical entity. Although we praise this approach, our gerontological souls are still bleeding. Something has been lost in the translation from construct to measurement. Perhaps, to understand this feeling of incompleteness, we need to abandon for a moment the stringency of the statistical approach and explore the cultural and historical development of aging and frailty as related concepts.

According to the latest edition of The Oxford Dictionary, frailty is the "liability to be crushed or to decay, either in material or immaterial sense ... moral weakness, instability of mind, liability to err or yield to temptation" (2). On a broad historical perspective, it is interesting to explore how cultural and religious perceptions of old age have developed over time and how aging became associated with the negative concept of frailty. In ancient times, elderly persons were revered, as they served as the repositories of cultural heritage, especially at a period when culture was transmitted orally, dependent on their accumulated memory and experience [See, e.g., (3)]. With the beginning of the written word, the revulsion due to frailty and decadence of old age has prevailed over more positive views. It is interesting to explore the transition from the first to the second period.

In the ancient "folk" understanding across cultures, old persons were somewhat affiliated with the supernatural and functioned as intermediary between humans and gods. According to David Gutmann, the anthropological explanation of the respect for the aged may lie in the fact that the aged "are moving into the country of the dead" where "a strong spirit is revealed ... no longer masked by the vitality of the young body" (4). For the Greeks, equivalence between longevity and physical decadence is a limit only for humans. In fact, gods can age and remain fit. It is through "foolishness," or forgetfulness, rather than necessity, that living long becomes associated with frailty: Eos asked of Zeus that Tithonos may be deathless but forgets to ask for agelessness and its specific corollary, eternal youth, therefore bringing to her lover eternal aging. Interestingly, a "wise" solution to this dilemma was to transform Tithonos into a cicada (tettix). Greeks believed the cicada, being almost free from the need of food and at the same time having an extremely short life, to be a symbolic bridge between the ageless immortals and humans (5). The parallelism of this mythology with the current studies on caloric restriction and longevity is striking.

The Bible is filled with images of reverence toward elderly people. At the same time, we see a transition toward a negative perception of aging because of the associated frailty. Mishnah, in one of the earliest recordings of the Rabbinical Jewish oral law, argues: "He who learns from the old is like one who eats ripe grapes and drinks old wine" (6). Aging represents a welcomed pilgrimage through the transitions of life. The Book of Jubilees (23:11) reinforces the lack of equivalence between aging and frailty by stating that the "calamitous days" of old age only occur as the effect of premature aging (opposed to normal aging), which is the consequence of sin: "Abraham was perfect in all his deeds ... all the days of his life, ... [on the contrary] the generations which shall arise from this time until the day of the Great Judgment shall grow old quickly ..." Note that this interpretation is consistent with the notion of frailty as a condition of "accelerated aging." However, many passages that presuppose the revered notion of the aged take vigorous issues with the assumption (Ps.119:100; Job 12:12; 32:9; Ecc. 4:13). Age per se is not a condition for blessing (7). In the Midrash, it is said that "there is an old age without the glory of long life; and there is long life without the ornament of age: perfect is that age which hath both."

From about 500 B.C., the Indian culture, especially under the influence of Buddhism, saw aging as an unremitting agony of the impermanent and impure physical body, which can be liberated only by death or sacralization. Frailty is therefore not a disease, but a natural transformation over the life course that leads to salvation. It is striking to see how physical aging in the Indian culture and the modern concept of frailty as a derangement of the networks that maintain the homeostatic equilibrium share similarities. In the Indian tradition, the essence of aging permeates all the stages of life, even childhood. However, in young persons, the signs of old age are not visible because the predominance of humor of water (kaphadosa) keep them balanced in "the future timeframe." With time, the "homeostatic" force of the humor of water declines and paves the way for the humor of wind (vatadosa) to emerge and become dominant. As a consequence, the signs of old age leave their future and enter their present timeframe. If this phasic modification can be delayed, a person is perceived to be young even in old age because, in some way, the dynamic equilibrium between the various humors is maintained. In other words, though aging continues to take place from the moment of birth, it is detected only after a certain period of time has elapsed (8).

In medieval times, under the influence of the Arabic medical literature, aging is the natural decreasing of the oils that nourish the flame of life. The use of oil can be optimized (for example, by a lean diet) so that the flame can burn strong for a long time, although the process that ultimately produces exhaustion is still there. On the other hand, the interpretation of the aging process as the "advanced wasting of the innate heat until it become inadequate to keep up with the remaining radical moisture" is typical of the Galen's school and would suggest limited possibility for prolonging life through external intervention or artifices (9).

In cultures where physical decadence and aging are thought to be inextricably connected, extreme longevity becomes the worst imaginable fate. In Chaucer's "The Pardoner's Tale," a man is punished with immortality, his misery being denied death. The old man is a figure of the horror of never-ending existence and the denial of transcendence. Frailty is produced by the denial of death (10). Centuries later, Jonathan Swift revisited this concept in Gulliver's Travels (chapter 10, book III). Gulliver is informed about the immortal "struldbrugs." He is excited about the notion and thinks of immortality as an infinite opportunity for accumulating wealth and knowledge. Soon he realized that what is accumulated is mostly misery and suffering: "when they come to fourscore years, which is reckoned the extremity of living in this country, they had not only all the follies and infirmities of other older men, but many more which arose from the dreadful prospect of never dying." For Swift, death is natural, providential, necessary, and universal, a relief from the agonies of the frailty of old age, and hence not an evil to avoid. Death is a blessing, if the alternative is to become a struldbrug, that is, frail (11).

The definition of different stages of life, typical of medieval literature on the subject (12), is the response to the need to distinguish between frailty as an affliction, and the late stage of life when we prepare to travel to the beyond. Therefore, there is an attempt to "treat" frailties of old age as diseases but also a consciousness of not trying to defy death, which is a passage to transcendence and salvation. Not to be frail is a blessed state insofar as it does not mean delaying death. Here, an ethical paradox toward aging emerges that runs through some of the most famous literary works: in Faust, "The Pardoner's Tale," The Picture of Dorian Gray, and Dracula, escaping from the inevitable frailty of old age is perceived as immoral. Frailty is evil but freedom from it is devilish, as it requires selling one's soul to the devil. The ageless immortality is a claim to godliness, a blasphemy in monotheistic religions. However, this is not a purely medieval heritage. Remember—the "foolishness" that divided between agelessness and immortality became the curse of frailty for Tithonos. There is a heavy price attached to immortality, as long as death is a path to salvation.

Even from this very brief and simple historical and anthropological excursus, it is clear that, in different populations and historical times, the relationship between aging and its associated physical decadence (which is somewhat analogous to the concept of frailty) is intrinsically connected with religious beliefs, traditions, and customs. Perhaps, from this perspective, it becomes more clear why modern geriatrics has dedicated so much time, energy, and resources into demonstrating that, over the life span, the trajectories of longevity and frailty can be totally segregated, individually defined by strict operational definitions, and attributed to different modulating factors. Not surprisingly, this view is consistent with the technological vision of modern medicine where all the elements of human sufferance can be isolated, defined, and potentially treated, even when they are as complex and multidimensional as age-related frailty. In principle, there is nothing wrong with this perspective. Being thoughtful scientists of our time, we all have the dream to identify, prevent, and treat frailty. However, we should also preserve a healthy skepticism and not rule out the possibility that aging and frailty are intrinsically connected and evolve in parallel. Incidentally, over the last 50 years, total life expectancy has increased much more than active life expectancy, and therefore, similar to "Eos' foolishness," we have come closer to achieving "immortality" than agelessness, a problem that requires a metamorphosis of our approach to aging and frailty, and an understanding that mediates between these two closely knit concepts.

Geriatric medicine deals with older persons, many of whom suffer under the burden of multiple morbidities, disability, social isolation, and mood disorders. Although the geriatric approach guided by comprehensive geriatric assessment has shown some positive results even in these "difficult patients," we desperately need new knowledge that can be translated into more effective interventions. The solid validation of an operational definition of frailty that can be used in geriatric practice and in clinical research reported in this issue of the Journal is an important step in this direction. So, why are our gerontological souls still bleeding?

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