This piece in the NY Times by a geriatrician is nicely done. As someone who is older and will be hitting those geriatric years sooner than I might like, the cruel ageist attitudes we’ve seen in recent days is more than a little bit depressing. I realize that Joe Biden is in the most high pressure difficult job in the world and we all have a perfect right to be concerned about his ability to handle it. (I only wish everyone was as concerned about his opponent’s obvious intellectual and character deficiencies.)
I think this is a sensitive analysis of what may be going on with Biden:
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.
[…]
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 cognitively impaired, nor does it mean they are imminently dying.
This does not answer the question of whether or not he can win the campaign which is the whole ballgame. In this era, most results are determined by party ID now with a few undecided voters who may or may not know or care about any of this so maybe it isn’t as important as we might think. One thing we do know is that every president ages in office due to the immense pressures of the job. Even the young ones look like they’ve been pummeled in a bar fight when it’s over.
As for whether he can be president for 4 years, I am skeptical. But as Stuart Stevens said this morning on MSNBC, worrying about that is like worrying about your cholesterol in the middle of a knife fight. It’s all about who can win and that is not obvious at this point. (Everyone voting for him knows the chances that the VP will end up taking over are high and will factor that into their vote. )
All that aside, I think this does offer a reasonable explanation for what may be happening with him that suggests all the hysteria about a “cover up” and the nasty reporting that cruelly degrades him is off base. These things don’t happen all at once and it’s not clear that people would have been specifically aware that something tangible had changed until recently.
The question he and others have to decide is whether having “good days and bad days” or being frail enough that he gets thrown off balance from stress and minor illness will keep him from being more able than Harris or someone else to beat Donald Trump. That’s all that matters right now and I don’t know the answer.
The one thing I do know is that Biden may have good days and bad days but every day with Donald Trump in the White House will be a nightmare.
