Critical perspectives on ageing and late life

This paper is ground in a critical gerontology that considers how late life is structured and experienced (Baars et al., Reference Baars, Dohmen, Grenier and Phillipson2013). It draws together political, economic and social relations (Townsend, Reference Townsend1981; Estes, Reference Estes2001; Estes et al., Reference Estes, Biggs and Phillipson2003) with an interpretive (Cole et al., Reference Cole, Ray and Kastenbaum2010) and cultural analysis of ageing and late life (Twigg and Martin, Reference Twigg and Martin2015) in order to explore taken-for-granted assumptions, and consider how interpretations and responses to ageing may enable and constrain the lives of older people (Estes et al., Reference Estes, Biggs and Phillipson2003). Insights from this perspective offer a lens to consider how frailty takes on meaning in social and cultural contexts, and becomes enacted in policy and practice frameworks across a range of contexts (see Estes et al., Reference Estes, Biggs and Phillipson2003; Hendricks, Reference Hendricks2004; Grenier, Reference Grenier2012).

The paper employs a critical discourse analysis that takes account of political, social and economic conditions that create and sustain social relations and powerful practices (Fairclough, Reference Fairclough, Wodak and Meyer2001; Marston, Reference Marston2004). Critical discourse analysis is concerned with how social power is ‘enacted, reproduced and resisted by text and talk in the social and political context’ (van Dijk, Reference van Dijk and Van Dink2001:352). This includes an analysis of how discourses shape expectations or micro-discourses, and mediate interactions between groups and macro-level structures. The particular reading employed in this analysis combines an analysis of textual sources (Fairclough, Reference Fairclough, Wodak and Meyer2001) with a reading of policy guidelines and personal accounts as stories (Biggs, Reference Biggs2001; Hendricks, Reference Hendricks2004). In an approach modelled by Bytheway (Reference Bytheway2011), this paper cites verbatim quotes from published social science and humanities literature on frailty over the last 25 years. More specifically, it grounds the analysis through engagement with a public document geared to set the international agenda: the White Book on Frailty (Vellas et al., Reference Vellas, Cesari and Li2016).

The biomedical and geriatric development of frailty

The study of frailty grew out of related enquiry into longevity and mortality, and since the 1990s has received widespread attention in health, clinical medicine and geriatrics (Rockwood et al., Reference Rockwood, Fox, Stolee, Robertson and Beattie1994; Fried et al., Reference Fried, Tangen, Walston, Newman, Hirsch, Gottdiener, Seeman, Tracy, Kop, Burke and McBurnie2001; Bortz, Reference Bortz2002). In general, frailty refers to a syndrome or construct used to refer to risk of death, functional decline, co-morbidities and impairment (Clegg et al., Reference Clegg, Young, Iliffe, Rikkert and Rockwood2013). Following this, the state of knowledge extended into whether frailty was related to age, natural decline or disease, co-morbidity, and approaches based on deficit models and ‘clinical relevance’ emerged. The debate at present can be described via two theoretical explanations. The first is a phenotype model, whereby frailty is considered a distinct syndrome characterised by poor physical performance across a range of domains including unintentional weight loss, weakness/grip strength, slow walking speed and/or low levels of physical activity (Fried et al., Reference Fried, Tangen, Walston, Newman, Hirsch, Gottdiener, Seeman, Tracy, Kop, Burke and McBurnie2001). The second is an accumulation of deficits model whereby frailty is the cumulative effect of stressors and deficits in multiple domains that accumulate over time, and place people at risk for adverse outcomes (Rockwood et al., Reference Rockwood, Fox, Stolee, Robertson and Beattie1994; Rockwood and Mitnitski, Reference Rockwood and Mitnitski2007).

Contributions from the biomedical disciplines, including geriatric medicine, have primarily focused on the physical rather than social aspects of frailty. In a recent review assessing the extent to which frailty is used in social care, Manthorpe et al. (Reference Manthorpe, Iliffe, Harris, Moriarty and Stevens2018) document four ways that frailty is used in the UK. This synthesis is helpful in providing a quick overview unencumbered by existing tensions in the field. According to Manthorpe et al. (Reference Manthorpe, Iliffe, Harris, Moriarty and Stevens2018: 25), frailty is currently employed in the UK to refer to: ‘1) a group that are ill and/or “disabled”; 2) people who are vulnerable and/or at risk of adverse outcomes from even relatively minor illnesses; 3) physical changes that can be documented and measured; and 4) an accumulation of deficits and/or disabilities’. Together, these aspects represent the key biomedical and geriatric interpretations of frailty as a biomedical condition or classification related to impairment, dependence and decline. They also reflect the dominant lens through which ‘frailty’ is approached in health documents, geriatric medicine and across a range of health-care settings.

Key themes from the social sciences and humanities literature

A review of the social science and humanities literature in the last 25 years reveals a slightly different set of themes with regards to frailty. Where countless articles make use of frailty as a taken-for-granted descriptive classification or reference point (i.e. advanced age), and have been excluded from discussion here, there is a growing literature that is both critical of the dominant biomedical discourse, and which offers insight into the social, cultural and lived experiences of frailty. This section focuses on the scholarship that is concerned with unpacking the meaning of frailty, much of which is drawn from interpretive insights of older people and/or explorations of the use of the concept in practice. The common thread in the articles written from a critical perspective is the critique of frailty as a biomedical condition and a biopolitical practice – a distinction that is visible in the contrast between professional and lay accounts of frailty and/or ‘being frail’ (Kaufman, Reference Kaufman1994b; Grenier, Reference Grenier2006; Pickard, Reference Pickard2014, Reference Pickard2018; Tomkow, Reference Tomkowin press). Included is the longstanding resounding message that while frailty is used by professionals in research and practice, older people do not consider or refer to themselves as ‘frail’ (Kaufman and Becker, Reference Kaufman, Becker, Smyer, Schaie and Kapp1996; Grenier, Reference Grenier2007; Nicholson et al., Reference Nicholson, Meyer, Flatley, Holman and Lowton2012).Footnote ⁴ Three themes from the social sciences and humanities literature on frailty are detailed below.

First, the critical literature based on insights from older people outlines that frailty is a socio-cultural construct. Frailty and the ‘fourth age’ are discussed as socio-cultural constructs, examples of classification practices used to determine eligibility for care, a symbolic marker between activity and decline, and a potentially meaningful location in later life (Lustbader, Reference Lustbader2000; Grenier, Reference Grenier2012; Lloyd, Reference Lloyd, Twigg and Martin2015; Tomkow, in press). Early in the social sciences work on frailty, Gadow (Reference Gadow1983) drew attention to frailty and strength as a dialectic. She argued that the negative value of frailty reflects a rationalistic view of the body and self as adversaries. In 1994, Kaufman explored the socio-cultural dimensions of frailty as experienced by older people in the USA – extending understandings of frailty beyond instrumental use in care practice (Kaufman, Reference Kaufman1994b). Building on this, Grenier (Reference Grenier2005) outlined how frailty was a social and contextual experience that took place in relation to the home (e.g. baths, stairs, handles), ‘getting around’ (i.e. bus) and encounters with care systems. More recently, distinctions between the biomedical and the socio-cultural nature of frailty have also been carried out in the UK with a strong line of critique centred around the notion of ‘fourth age’ (Pickard, Reference Pickard2009, Reference Pickard2018; Nicholson et al., Reference Nicholson, Meyer, Flatley, Holman and Lowton2012; Tomkow, in press). Gilleard and Higgs (Reference Gilleard and Higgs2013), for example, have suggested that the ‘fourth age’, noted by similar features to frailty (i.e. decline, impairment, pending mortality, etc.), is a ‘social imaginary’ – a ‘black hole’ characterised by a void of potential and an absence of agency (Gilleard and Higgs, Reference Gilleard and Higgs2010, Reference Gilleard and Higgs2011). Although this focus on the social imaginary has drawn attention to the significance of theorising late life and deep old age, it has also produced new challenges with regards to notions of dependency, decline and agency (Twigg, Reference Twigg2006; Lloyd, Reference Lloyd, Twigg and Martin2015; Grenier et al., Reference Grenier, Lloyd and Phillipson2017). The following quotes illustrate the reading of frailty as a socio-cultural construct:

Second, the critical literature from the social sciences and humanities discusses how frailty is a historically situated practice of classification linked to biomedical assessments, care management systems and individualised interpretations of risk. The contemporary construct of frailty, and the accompanying practices of assessment and classification, emerged as a means to determine eligibility for service within a managed care model in the USA. Kaufman (Reference Kaufman1994a, Reference Kaufman1994b) was the first to expose frailty as a social construct and practice connected to discourses of risk, geriatric assessment and managerial care models in the USA (see also Kaufman and Becker, Reference Kaufman, Becker, Smyer, Schaie and Kapp1996). Writing against a similar backdrop, Grenier (Reference Grenier2007) outlined how frailty, as enacted through functional assessments in Canadian home-care practices, represented a dividing practice that disciplined older bodies, and used these classifications to determine eligibility, thereby reducing service demand and restricting access to public care (see also Grenier, Reference Grenier2005; Grenier and Hanley, Reference Grenier and Hanley2007). Such critique is now also present in the context of the UK, with Tinker et al. (Reference Tinker, McCreadie, Wright and Salvage1994), Pickard (Reference Pickard2009) and Tomkow (in press) drawing attention to how frailty is understood in relation to biomedical practices and policies, such hospital discharge. As such, authors in the social sciences and humanities flag the linkage between frailty, individualised interpretations of risk in the context of medical and market-led models of care, and the retrenchment of public support (Kaufman, Reference Kaufman1994a, Reference Kaufman1994b; Grenier, Reference Grenier2007) – a phenomenon that Tomkow (in press) has eloquently analysed as ‘biopolitical practice’. Witnessed across the contexts of the USA, Canada and the UK, the critical social science literature demonstrates the enactment of frailty as a powerful practice, the alignment with individualised interpretations of risk and the global reach of managerial care systems that rely on standard assessment, and by means of limiting access to care rely heavily on individual, family and kin for care. The following quotes illustrate the relationship between assessment and managed care:

Third, the critical social science literature outlines that frailty is also an embodied, emotional and relational experience. A number of authors have drawn attention to the subjective experiences of frailty, how the impairment of frailty prompts adaptation and the emotional vulnerability of ‘being frail’ (Becker, Reference Becker1994; Kaufman, Reference Kaufman1994b; Grenier, Reference Grenier2006; Woodward, Reference Woodward2015). A number of authors have noted the relationship between frailty and loss – a theme that has endured throughout the 25 years of inquiry (Holman et al., Reference Holman, Meyer and Cotter2004; Lloyd et al., Reference Lloyd, Calnan, Cameron, Seymour and Smith2014). Early work on frailty suggested that experiences may provide opportunities to embrace the body (Gadow, Reference Gadow1983), strengthen relationships with family (Lustbader, Reference Lustbader2000), and narrate life experiences and discussions of death (Taylor, Reference Taylor1992). Writing from the humanities, Woodward (Reference Woodward2015:349) analyses the feelings and experiences of frailty that are conveyed in Joan Didion's Blue Nights, thus contributing another angle to understandings of how older people negotiate experiences of impairment, decline and vulnerability (Grenier, Reference Grenier2005; Grenier and Hanley, Reference Grenier and Hanley2007; Nicholson et al., Reference Nicholson, Meyer, Flatley, Holman and Lowton2012; Lloyd et al., Reference Lloyd, Calnan, Cameron, Seymour and Smith2014). This trend was perhaps sparked by Smith, who raised questions at the Valencia Forum in 2002 about whether the fourth age was a period of adaptation to psychological mortality (Baltes and Smith, Reference Baltes and Smith2002).

One of the key messages conveyed in the social science and humanities literature is thus how impairment that occurs in later life, and in proximity to the end of life (often labelled or referred to as frailty) bring the emotional and relational aspects to the fore. Where Lloyd et al. (Reference Lloyd, Calnan, Cameron, Seymour and Smith2014) have focused on identity, adaptation and dignity in the fourth age, Nicholson et al. (Reference Nicholson, Meyer, Flatley, Holman and Lowton2012) have turned to the experiences of ‘being ‘frail’ as a means to explore living and dying from within a frail state. The following quotes illustrate the idea of frailty as an emotional and relational experience of vulnerability:

The White Book on Frailty: the consolidation of a dominant domain

The paper now turns to explore the White Book as an international initiative aiming to guide understandings and practices with regards to frailty. According to the Oxford Dictionary of English (Stevenson, Reference Stevenson2010), a white book is ‘a book of rules, standards, or records, especially an official government report, bound in white’. Often intended as a means to spark a response to a particular issue, a white book is intended to set the disciplinary boundaries or parameters for knowledge and practice.

The preface of the White Book states its intent as follows:

As such, it exists alongside efforts to establish disciplinary boundaries through scientific conferences (e.g. International Conference of Frailty and Sarcopenia Research), research networks (e.g. Canadian Frailty Network) and peer-reviewed journals (e.g. The Journal of Frailty and Aging, established 2012).Footnote ⁵ While the White Book was produced by an academic association rather than a government body, its classification as a ‘white book’ rhetorically positions it as an attempt to establish a state of knowledge and standard(s) for practice. The White Book can thus be considered as a text that marks a historical moment in knowledge and practice on frailty, and as such, plays a role in consolidating the domain of expertise and practice on frailty.

The questions raised from a critical social science perspective are: What understandings or state(s) of knowledge are discussed and promoted? What is the dominant reading and suggested direction(s) for the field? Have (and how have) alternate forms of knowledge been incorporated? A scan of contributors and papers indicates that the reading of frailty being promoted is one of frailty as a biomedical disciplinary domain focused on physical aspects of impairment. The operational definition offered is of frailty as a preventable clinical state and/or functional impairment linked to decline, risk and vulnerability. The White Book opens with the following:

A page later, frailty is defined as a ‘state of increased vulnerability to the stress that carries an increased risk of disability, functional decline, hospitalization and mortality in older adults’ (Vellas et al., Reference Vellas, Cesari and Li2016: 3). Where the stated concern is the condition of impairment and decline, the related concerns of hospitalisation and death are added to the definition. The document then proceeds with a compilation of academic position papers on frailty reflecting the biomedical and geriatric approaches outlined earlier in this paper. The collection does not include perspectives from the social sciences, humanities or older people.

The academic position papers of the White Book are accompanied by a promotional video entitled ‘Beware of Frailty’ (available in nine languages). Such promotional materials are part of larger research agendas of engaging in what is known in Canada as knowledge mobilisation, and in the UK as implementation science. The idea behind such initiatives is to achieve social responsibility or impact through sharing evidence and research-based findings beyond academia to public and user groups.

Analysis of the promotional video that accompanies the White Book portrays a reading of frailty as something to be feared. Images and texts in the video ‘Beware of Frailty’ are used to caution the older person about the risks and perils of frailty (i.e. weakness, weight loss, slow walking speed, fatigue), link these symptoms with frailty and the loss of independence, and underscore the need for medical intervention. Older people appear silent in the video, acting out the motions and activities that are commonly used to assess frailty, including climbing stairs, getting dressed and walking. The professionally identified risks appear in script over the images, accompanied by slow music, and end with the statement: ‘Solutions are available, so do talk to your doctor’ (for the video, see http://frailty.net/frailty-news/international-initiatives/beware-of-frailty/). Both the academic position papers and the video define frailty as a functional risk, and situate the knowledge and suggested directions within a biomedical domain of professional practice.

Review of the White Book reveals that lay insights, or experiences from older people, are missing. This is a crucial point when considered against the consistent finding from the social sciences and humanities that ‘older people do not consider themselves or identify as frail’ (Kaufman and Becker, Reference Kaufman, Becker, Smyer, Schaie and Kapp1996; Grenier, Reference Grenier2007; Nicholson et al., Reference Nicholson, Meyer, Flatley, Holman and Lowton2012) and further, that the term ‘frail’ may be less frequently used by practitioners in contemporary social care contexts (see Manthorpe et al., Reference Manthorpe, Iliffe, Harris, Moriarty and Stevens2018). It is also important where involvement of user groups is considered as a ‘best practice’ for mobilising knowledge (Anderson and McLachlan, Reference Anderson and McLachlan2016). While it is not clear whether an advisory board was involved in the development of the document, or production of the video, the silence of the older actors is striking.

The release of a White Book on Frailty that does not include experiences from older people, even by proxy quotes from advocacy groups or published works from the social sciences and humanities, is puzzling. Admittedly, the absence of insights from older people is not only the case of the White Book. Guidelines and practices written about older people often overlook the voices of groups deemed ‘too marginal’ to speak for themselves. Publications and videos such as these could, however, draw on insights from campaigns such as that of Age UK (see Ipsos Mori for Age UK, 2014; Age UK, Reference Age2015; BritainThinks, 2015)Footnote ⁶ who have solicited the insights of older people and their carers. The authors of the White Book could also partner with such organisations to define frailty and determine practices and approaches that are inclusive of older people's needs and wishes. Here, insights from the social sciences and humanities that were derived from interpretive research with older people have much to offer.

Yet, to what extent have some of the key contributions from the social sciences and humanities been incorporated? The results are mixed. The White Book includes reference to some social aspects of frailty, primarily through a social determinant of health model lens.Footnote ⁷ In this sense, the state of biomedical knowledge on frailty has shifted enormously over ten years, from an almost exclusive focus on function and impairment, to include social dimensions such as the environment and the long-term effects of disadvantage (see Grenier, Reference Grenier2007; Manthorpe et al., Reference Manthorpe, Iliffe, Harris, Moriarty and Stevens2018). However, although now inclusive of ideas such as dependence, social vulnerability and the social determinants of health, the suggested definition and response fall short where considerations of the powerful practices that accompany frailty, and the cultural fears of ageing and decline, are concerned. Although some entries in the White Book (Vellas et al., Reference Vellas, Cesari and Li2016) acknowledge social factors (Bousquet et al., pp. 48–49; Gutierrez-Robledo and Avila-Funes, pp. 118–119; Manal Suzana and Singh, p. 25; Rowe, p. 4; World Health Organization, p. 7), physical and psychological/mental wellbeing (Bousquet et al., pp. 48–49), or disadvantage and vulnerability (Gutierrez-Robledo and Avila-Funes, pp. 118–119; Rockwood and Mitniski, p. 16; Rowe, p. 4; World Health Organization, p. 7), the overall model clearly retains frailty as the domain of health and medicine, and a physical condition to be measured and treated. The White Book paper by Gutierrez-Robledo and Avila-Funes, for example, articulates the relationship between social and functional criteria as follows:

The dominant definition of frailty that is established and sustained through the White Book is of frailty as a ‘preventable condition that requires a health response’. As such, it is a reading that privileges biomedical and expert knowledge about function and decline over the emotional and embodied experiences of acquiring impairment in late life, including ‘ruptured life narratives’, identities or the need for care (Grenier, Reference Grenier2006, Reference Grenier2007; Lloyd, Reference Lloyd, Twigg and Martin2015). In doing so, it misses the importance and opportunities to build on stories as a means to improve perceived health and/or wellbeing. The inherent contradiction, however, is that while the dominant approach conveyed in the White Book overlooks the interpretive dimensions related to frailty and impairment, it calls upon these very vulnerabilities to achieve its rhetorical purpose. The awareness video acutely employs the socio-cultural fear of impairment and decline (i.e. ‘Beware of Frailty’) to situate frailty as a problem of individual risk, and to suggest medical intervention as a solution (i.e. ‘speak to your doctor’). In doing so, it establishes a powerful link between symptoms, the clinical state/condition (whether perceived or objectively observable), the problem (one that is stated to be reversible) and the suggested solution (i.e. medical intervention). The intent in this article is not to question the existence of frailty as a health issue, nor the need for response, but to highlight the symbolic and rhetorical use of the cultural fear of ageing and decline as a means to consolidate and reinforce professional power.

‘Significant absences’: recognising the social, political and emotional

This section employs the notion of ‘significant absences’ to reflect on the knowledge and perspectives that are missing from the dominant international research and practice agenda on frailty, as exemplified in the White Book and the accompanying promotional video ‘Beware of Frailty’. McMahon (Reference McMahon1996) uses the concept of ‘significant absences’ in qualitative research to highlight ‘how research accounts can conceal the experiences of those who do not seem present in the research project’. In this article, the idea of ‘significant absences’ is used to reflect on broader knowledge claims that are being made about frailty, the inherent power and expertise that are expressed in doing so, and the extent to which voices, such as those of older people, remain excluded from the debate. As such, it considers both the processes that may prevent this knowledge from being acknowledged, and what may be hidden or lost through these omissions.

The ‘significant absences’ of frailty are social, emotional and political. Review of the White Book, when set against contributions from particular sets of disciplinary scholarship, reveal that older people's perspectives, either by means of personal accounts or through accounts from the social sciences and humanities (gathered by means of in-depth interviews with older people who are ‘frail’), have not made it into the dominant recognised and legitimated forms of knowledge and practice. The White Book overlooks the emotional connections with loss and vulnerability, and falls short in situating frailty within political and historical approaches to ‘need’ and care.Footnote ⁸ The dominant definition of frailty overlooks the interconnected relationship between the assessment of frailty and contemporary neoliberal practices characterised by the reduction of public systems of care and support. This includes how definitions and assessments of frailty are implicated in a complex web of political changes to care over time, the erosion of social care, the severity of impairment needed to qualify (or compete) for scarce services, and the reliance on family or kin care. At no point does the dominant model presented leave space to question the means by which classifications of frailty are used to provide (or restrict) access to services within residual models of home, community or hospital care.

The question for critical social sciences and humanities scholars is thus: how might we explain this conspicuous absence? Four possibilities can be considered. First, the White Book primarily involves medical and health professionals. The absence of critical findings from the social sciences and humanities (and therefore the omission of older people's voices) may thus be a reflection of what policy makers refer to as ‘working in silos’ or an absence of ‘joined-up services’. That is, it may reflect historical disciplinary and research approaches where boundaries are difficult to cross, and result in missed opportunities for shared knowledge. Second, the absence of insights from the social sciences and humanities, and of older people, may reflect longstanding power relations and hierarchies between disciplines and/or professional/lay knowledge, and in particular, an attempt to define and regulate frailty as a biomedical domain (see Pickard, Reference Pickard2014; Tomkow, in press). Third, overlooking the social, political and emotional aspects of frailty may be a reflection of a deeper de-politicisation of care, and/or lack of knowledge about the historical evolution of eligibility criteria and assessment practices related to social care (see Kaufman, Reference Kaufman1994b; Grenier, Reference Grenier2007). Finally, taken together, the oversight may simply reflect the strength of the cultural narrative surrounding frailty, including the reluctance to discuss decline, death and conditions that cannot be ‘cured’.

Thinking through the ‘significant absences’ that are present within agenda-setting initiatives on frailty offers a number of reconsiderations for frailty and late life. At present, the state of knowledge in the biomedical field is characterised by a debate between frailty as a syndrome, which overlaps with the concept of sarcopenia, and has resulted in a sub-strand of research on the ‘genetics’ of frailty (Fried et al., Reference Fried, Hadley, Walston, Newman, Guralnik, Studenski, Harris, Ershler and Ferrucci2005; Morley et al., Reference Morley, Vellas, van Kan, Anker, Bauer, Bernabei, Cesari, Chumlea, Doehner, Evans, Fried, Guralnik, Katz, Malmstrom, McCarter, Gutierrez Robledo, Rockwood, von Haehling, Vandewoude and Walston2013; Rodriguez-Mañas and Fried, Reference Rodriguez-Mañas and Fried2015), and a status derived from the age-accumulation of morbidity, impairment and disability, that has led to research that incorporates social aspects such as the environment and ‘social vulnerability’ (Morley et al., Reference Morley, Vellas, van Kan, Anker, Bauer, Bernabei, Cesari, Chumlea, Doehner, Evans, Fried, Guralnik, Katz, Malmstrom, McCarter, Gutierrez Robledo, Rockwood, von Haehling, Vandewoude and Walston2013; Rockwood, Reference Rockwood2013). Although it could be argued that the more socially inclined work within the biomedical sciences has growing affinity with the insights from the social sciences and humanities, such a position misses a crucial aspect of the argument of this paper. The qualities and processes that are conspicuously absent from the dominant discussions and agenda-setting initiatives inadvertently disguise practices of power within and across national and international health and social care agendas and practices (see also Tomkow, in press). It overlooks key insights that are clearly articulated in older people's perspectives, and the negative implications that could be taken up if such differences are attributed to physical/functional impairment or determinants of health, rather than subjective experiences of adaptation and loss (see Baltes and Smith, Reference Baltes and Smith2002; Grenier, Reference Grenier2006; Lloyd, Reference Lloyd, Twigg and Martin2015). For example, the message that is currently being promoted may too easily slip into reinforcing negative cultural notions of ‘disability as tragedy’ (Kafer, Reference Kafer2013) and/or ageing as a ‘decline narrative’ (Gullette, Reference Gullette1997).

The ‘significant absences’ approach to reading dominant messages on frailty such as those outlined in the White Book highlights the need to include alternate forms of knowledge in definitions and agendas on frailty, to consider and expand the disciplinary boundaries, and to reflect on how doing so may substantially alter existing knowledge and practice. Attention to the social, emotional and interpretive experiences that accompany impairment, such as pain and/or loss, would bridge differences between professional understandings and older people's insights better. It may alter approaches from function and the response to instrumental needs, to more social interventions. It would also re-situate research and practice on frailty as inclusive of the concerns expressed by people with mental health issues and/or the disability movement (see Sayce, Reference Sayce2001; Priestley, Reference Priestley2003). Such shifts in recognition and practice would underscore the need for systemic supports to individuals and families that extend beyond instrumental health and function, and into the more social and relational aspects of care.

In moving forward, discussions and practices must acknowledge better how research and responses to frailty are deeply implicated in the politics of ageing and the politics of care. On an academic level, contemporary understandings of frailty could be strengthened by reference to the emerging work on bodies and materiality where, for example, frail bodies come to be understood in and against a biopolitical context that involves powerful institutions, biotechnological interventions and relational experiences such as care (see Katz, Reference Katz2018). This includes how the construct and practices organised around frailty are representative of a global trend of reduced public supports and a widening private (and for profit) enterprise around care for older people (see Estes, Reference Estes1993). Case in point is how the analysis of practices of frailty have shifted over time and international contexts, marked initially in the USA (Kaufman, Reference Kaufman1994a, Reference Kaufman1994b), then in Canada (Grenier, Reference Grenier2007) and later in the UK (Pickard, Reference Pickard2014, Reference Pickard2018, Manthorpe et al., Reference Manthorpe, Iliffe, Harris, Moriarty and Stevens2018; Tomkow, in press). Such timelines may suggest a reading of frailty as part of an international spread of neoliberal practices designed to reduce and restrict access to care as a means to control cost. An approach that integrates both the social and emotional phenomenon of frailty and the ‘politics of frailty’ as outlined in the social sciences and humanities may, however, dramatically alter understandings of frailty and need. Such a reading would reveal how need, the process of seeking care and the subsequent response to frailty occur in a political and economic context where the rhetoric of burden and the intersecting focus on cost containment and efficiency dominate the landscape. It is against this context that the changes from a ‘dependent population in need of care’ to a ‘frail’ person, subject or actor who is individually responsible for their own wellbeing become not only politically charged at the end of life, but a point of pressing social concern.