Article
Ageing
Care
Change
5 min read

Delicate, fragile, frail: how we cope when we age

The insights and analogies that help.

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

An old woman wearing a shawl looks pensive.
Valentin Balan on Unsplash.

“Who could dissect a portion of the human frame without marvelling at its delicacy, and trembling at its frailty?” mused preacher Charles Spurgeon in the nineteenth century. Songwriters, artists, authors and surgeons alike are fascinated by frailty. Within, beneath and beyond that fragile frame though, could there be a deeper reality, waiting to arise – and endure? 

Fragile Lives is the ‘heart-stopping memoir’, operation by operation, of heart surgeon Professor Stephen Westaby. “The finest of margins,” he writes, “separates life from death, triumph from defeat, hope from despair – a few more dead muscle cells, a fraction more lactic acid in the blood, a little extra swelling of the brain. Grim Reaper perches on every surgeon’s shoulder.” 

To what shall we compare this fragility of frame? - which means we can shatter sudden as glass, our “breath becoming air” in the blink of an eye? (Paul Kalanithi, a young neurosurgeon, called his memoir When Breath Becomes Air as he fought his own battle with cancer). A snowflake? A spider’s web? A butterfly wing? In Dutch still life paintings, the transience of life is variously depicted in dry, fallen withering petals, rotting fruit, and a glass vessel, like a vase. At some funeral services, it is said that we are made from dust, and to dust we shall return. Elsewhere in the Bible, we are likened to a mist that appears for a little while and then vanishes, or to a flower that withers away, a fleeting shadow that does not endure. Our days are a mere handbreadth, our life but a breath, writes one Bible songwriter. 

Medics talk more commonly of frailty than fragility – and it’s not just a byword for old age. According to the British Geriatrics Society, not all old people live with frailty; not all people living with frailty are old, though age is a recognised risk factor, with nearly 40 per cent of adults aged 85-90 being frail. Described as a vulnerability to external stressors which can result in sudden marked deterioration in function, frailty might feature as a combination of falls, immobility, delirium, incontinence, and increased side effects of medications, suggesting the body is struggling to cope. “A minor infection or minor surgery results in a striking and disproportionate change in health state – from independent to dependent, mobile to immobile, or lucid to delirious,” writes a team of doctors in The Lancet

Frailty is a sign of advanced biological rather than chronological age. Often, it’s an unwelcome term, with consultant physician Patricia Cantley noting that, “from a patient or relative’s point of view, the word frailty seems to be at best somewhat vague and at worst, derogatory and demotivating”. She prefers to talk in terms of paper boats. Picturing young healthy patients as little tugboats of wood and steel, built to withstand storms, she likens the frail patient’s clinical situation to a paper boat, which can sail the sunny seas, but is soon buffeted and may be brought down by ‘medical winds’. 

Encompassing also psychological and cognitive symptoms alongside the physical, frailty is not a fixed state, nor is decline in mind and body inevitable once frailty begins. Seen increasingly as a dynamic spectrum, reversal of frailty is sometimes possible; the paper boat being, to a degree, storm proofed and made to chart a different course. According to Dr John Travers, professor of public health at Trinity College, Dublin, twenty minutes of daily exercise can reverse physical frailty and build resilience in over 65-year-olds, while others suggest that movement based mind-body therapies such as tai-chi and yoga can strengthen both mind and body. Could there also be something of a spiritual strengthening in the frail patient? As the body decays and declines, could the soul, the spiritual self, enlarge, emerge and ultimately endure as life ebbs away? This was certainly the sentiment of Paul, one of the early church leaders, in the Bible, who, after much suffering, wrote: “Therefore we do not lose heart. Though outwardly we are wasting away, yet inwardly we are being renewed day by day…we fix our eyes not on what is seen, but on what is unseen. For what is seen is temporary, but what is unseen is eternal.” 

Her late Majesty Queen Elizabeth II was seen on our television screens to diminish physically in her last days, her purple hands, tiny frame and walking cane causing concern among viewers. She was, at her funeral, described simply as “our sister Elizabeth”, her small coffin dwarfed by pageantry and a crowd of 2,000 including presidents and kings. And yet, the former Moderator of the Church of Scotland has revealed that she talked much of her Christian faith in her dying days, while her funeral was an explosion of scripture, hymns and sermons that expressed the strength of her personal faith. “It was her way of eloquently, beautifully and powerfully speaking to me and 4.1 billion other people of her Christian faith,” writes Pastor Skip Heitzig. For me, the funeral brought to mind the tides (continuing with the theme of the sea). As the tide recedes, the waters move away from the shore, in what is known as an ebb current. As the tide rises, water moves toward the shore in a flood current. As our Queen’s life ebbed away physically, her spiritual self arose, roaring like a mighty flood. Ocean motion, in currents, waves and tides, is driven by the sun, moon and the planets. Our late Queen also looked upwards, to her God, for spiritual succour that would turn life’s ebb to a soul-flood.  

Hymnwriter Timothy Dudley-Smith sought a similar exchange, from the physical to the spiritual, the mortal to the immortal, in yet more words about boats, in his hymn “My boat so small”, based on the Breton Fisherman’s Prayer. 

“Adrift when strength and courage fail, O Spirit, breathe to fill my sail” 

And, happily, he trusts a safe voyage, finishing with - “My voyage done, all trouble past, to haven bring my soul at last.” 

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Review
Art
Care
Culture
Mental Health
5 min read

Mental health: the art that move us from ostracism to empathy

Four current London exhibitions show the move towards compassion.

Susan is a writer specialising in visual arts and contributes to Art Quarterly, The Tablet, Church Times and Discover Britain.

A painting of a haunted looking old man dressed in an imagined military uniform.
A Man Suffering from Delusion of Military Rank.
Théodore Géricault, Public domain, via Wikimedia Commons.

Portrayals of mental health were revolutionised from the nineteenth century onwards. While previous generations had focused on the ostracism of those suffering mental illness, and the fear their condition aroused in others, modern artists began to focus on the dignity and humanity of sufferers. Four current London exhibitions show this move towards compassion. 

On display at the Courtauld’s Goya to Impressionism, Theodore Gericault’s A Man Suffering from Delusion of Military Rank, c.1819 -22, shows the artist’s sensitive response to ‘monomania’, the term coined in the early 1800s for people living with a single delusional obsession. It is thought this painting is part of a series of portraits on fixations including A Child Snatcher, A Kleptomaniac, A Woman Addicted to Gambling and A Woman Suffering from Obsessive Envy, the face of the last rendered in an unsettling green tinge. 

The circumstances surrounding the painting of the series remain mysterious. The timing coincides with Romantic painter Gericault completing his most famous work, the monumental The Raft of the Medusa, 1818-19, depicting 15 survivors of a shipwreck, who had been adrift on a makeshift raft, originally containing 147 passengers, from the French frigate Meduse. Gericault’s preparation for the canvas included visiting morgues to check on the colour of decomposing flesh and building a model of the doomed raft. His difficulties in completing the huge work, over 23 feet long, and the possibility some of his close family may have suffered from mental illness, have supported the belief Gericault painted A Man Suffering from Delusion of Military Rank, and related portraits for personal reasons, possibly out of gratitude to the physician who cared for his family. But there is now doubt if Dr Etienne-Jean Georget commissioned the painting, and whether he was chief physician at Saltpetriere asylum in Paris. 

Even if a biographical motivation for the series falls down, and there is no way of knowing if the subjects of the portraits were individuals living with mental health conditions, these portraits remain unique in early nineteenth century painting. People deemed at the very margins of society are portrayed in the same manner as the most powerful, in half-length portraits emphasising their dignity and humanity, over their social estrangement and health challenges. 

The Raft of the Medusa, Louvre, Paris. 

A painting shows a wreck of a rafter holding survivors and corpses.

Van Gogh’s mutilation of his own ear is interwoven into his biography and his art. In The Ward in the Hospital at Arles and The Courtyard of the Hospital at Arles, both 1889, the artist depicted the interior and exterior of the institution where nuns cared for him, during his mental health crisis. The paintings’ significance to his recovery is shown by Van Gogh taking them with him when he moved to another psychiatric facility 25 kilometres away at Saint-Remy-de-Provence. 

Blue is the dominant colour of The Ward, permeating the walls, the beamed ceiling, the crucifix and the door underneath it, and several patients. wear dark blue clothing, including the two nursing Sisters at the centre of the scene, whose Order of St Augustine black and white habits, have been realised in darkest blue. Van Gogh described the long ward as ‘the room of those suffering from fever’, most probably referring to patients with mental illness. The painting was reworked during the artist’s admittance at Saint-Remy-de-Provence, with the symbolic empty chair used in other works to represent him and his housemate Paul Gauguin added to the foreground, together figures gathered around a stove. The return to the painting was prompted by reading Dostoevsky’s The House of the Dead, a fictionalised account of the author’s spell in a Siberian prison, and the book’s characters may have provided the inspiration for the huddled men. 

The Courtyard of the Hospital at Arles captures the grace of the hospital’s Renaissance building, by depicting the inner courtyard from the vantage point of the first-floor gallery. From this aerial angled viewpoint, the garden’s bright flora, radiating from a central pond, spreads out in all directions. Van Gogh’s description of the scene to his sister Willemien, hints at their Bible reading, clergy childhood: ‘It is therefore a painting full of flowers and springtime greenery. Three dark and sad tree trunks however run through it like snakes…’ 

Van Gogh’s images of healing were from memory rather than life, and document his own mental health recovery:  

‘I can assure you that a few days in hospital were very interesting and one perhaps learns how to live from the sick.’ 

The Ward, Vincent van Gogh, Public domain, via Wikimedia Commons.

Van Gogh's painting of a mental ward in a hospital

Edvard Munch's Portraits, Evening 1888, shows the artist’s sister Laura, who had been hospitalised for mental illness, on and off, since adolescence. Although Laura is lost in her own world, staring fixedly ahead against a coastal landscape, the affection of the artist for the subject is palpable. Fashionably dressed in straw hat and summer dress, Laura’s dignity anchors the composition. Munch documented his own breakdown after alcohol poisoning in a portrait of Daniel Jacobson. His full-length portrayal of the doctor, arms akimbo, drew the reaction: ‘just look at the picture he has painted of me, it’s stark raving mad.’ Munch’s fascination with the doctor-patient relationship is evident in Lucien Dedichen and Jappe Nilssen, 1925-6, where Dedichen’s looming, purple presence, overshadows the diminutive, seated patient. 

Portrait, Evening. Museo Nacional Thyssen-Bornemisza, Madrid.

A painting of a  pensive young woman sitting and staring across a lawn.

Mental health and delusion form the wellspring of Grayson Perry’s Delusion’s of Grandeur. The artist responds to the Wallace’s flamboyant rococo collection in the persona of Shirley Smith, a character believing she is the rightful heir of the Wallace Collection. Eighteenth century style ceramics are decorated with outline figures resembling the Simpsons. Perry creates a family tree for Shirley from the Wallace’s miniatures, A Tree in the Landscape where every member has a condition from the American psychiatric guide Diagnostic and Statistical Manual of Mental Disorders. 

Grayson Perry, Untitled Drawing, Courtesy the artist and Victoria Miro. 

A image of a woman against a detailed red background.

In Alison Watt: From Light at Pitzhanger Manor, the artist’s still lifes of roses, fabrics and death masks responds to the collection of Regency architect Sir John Soane, and the ever-present fragility and complexity of human life and psychological flourishing. “With a rose it is impossible not to be aware of human intervention. Roses are bred, altered outside of nature and given names. In the history of painting the rose can be read as a symbol of beauty, innocence and transience, but also of decline and decay, echoing Soane’s preoccupation with themes of death and memorialisaton.” 

With the scientific and medical advances of the nineteenth century, life in all its psychological complexity, could supplant death as artists’ inexhaustible fount of inspiration. 

Le Ciel, Alison Watt.

A diseased rose.

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