March 05, 2013

Cynthia J. Brown, M.D., MSPH

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cynthiabrownCynthia J. Brown, M.D., MSPH, wants to change hospital culture and get patients out of bed.

Brown, an associate professor in the Division of Gerontology, Geriatrics and Palliative Care in the Department of Medicine at the UAB School of Medicine since 2003, studies what keeps older hospital patients in bed and the effects on patients’ function after they’ve been discharged.

Brown was recognized in late February 2013 as one of the top seven reviewers for the Journal of the American Geriatrics Society. She’s the 2013 recipient of the American Geriatric Society’s Outstanding Scientific Achievement for Clinical Investigation Award, which recognizes achievement in clinical research addressing health care problems of older adults by an investigator who is actively involved in direct patient care.

Brown’s focus on keeping patients moving started when she was a physical therapist providing inpatient and outpatient therapy for rheumatology and orthopedic patients. She had gotten her first chance to work with older patients as a high-school student when she volunteered at the Philadelphia-area hospital where her mother worked as a nurse. Brown said going to medical school never crossed her mind as she trained to be a physical therapist. But she grew more curious about the medical aspects and complexities of patient care, and, at age 32, entered the University of North Carolina School of Medicine.

“I knew that I wanted to work in geriatrics as a fourth-year medical student. I had an opportunity to spend a month on the geriatric service at UNC, working with some fabulous geriatricians and got very interested in that population, which wasn’t a big stretch—it was the same population I took care of as a physical therapist,” she said.

A lot of her skills from physical therapy training are key in treating older patients, because they not only have complex medical issues, many also suffer from incurable diseases. Brown said a lot of her job is helping patients adapt to their conditions so they can accomplish things they want in life.

After graduating from UNC in 1996, Brown went to the Yale School of Medicine and completed an internal medicine residency and chief resident year, followed by a three-year geriatric research fellowship. She noticed that when older patients spend time in hospitals, they don’t get out of bed, which can have detrimental effects to their lean muscle mass and muscular function.

Brown says that when patients spend a lot of time in bed in the hospital, by the time they are discharged they’re not able to do their daily living activities for themselves, even if they were able to do the activities before their hospital stay. Her first UAB study, using a data set from Yale University researcher Sharon K. Inouye, MD, MPH—one of Brown’s mentors—showed that patients with low mobility in hospitals were more likely to suffer functional decline and more likely to end up in a nursing home.

She’s also interviewed patients, nurses and doctors about hospital barriers that explain why patients aren’t getting up. Some of the answers are that there’s no one to help, not enough ambulatory devices (walkers, canes, etc.) for those who need them and general anxiety about falls. Brown said environment also plays factor, and most hospital rooms are designed around the bed – that’s where patients have the best view of the TV, and there aren’t extra chairs for patients who want to sit with visitors.

 “We’ve actually created this environment that encourages patients to stay in bed, and we’ve made it difficult for them to move around,” she said.

Brown recently completed a  study of geriatric patients at the Birmingham VA Medical Center.One group of patients received usual care and anther group  received  a “walking intervention” twice a day and a behavioral intervention where patients could talk about their post-discharge goals and any barriers to leaving their beds. Patients in the second group were also encouraged to tell their doctors of any pain, medical issues or ambulatory needs.

She said at the end of the study, patients who received the mobility intervention showed just a one-point decrease in their ability to get around in their community, but the control group saw a 10-point decline.

“Clinically, that’s a big deal because the intervention group was able to maintain and recover more quickly so that by one month after discharge, they looked very similar to when they were admitted to the hospital,” Brown said. “I think the key piece of the intervention was that we encouraged people. We helped them think of what they wanted to do after they were released from the hospital and helped motivate them to do it.” These patients were not only more active in the hospital; they were more active at home.

Brown recently applied for a grant from the National Institute on Aging to try to determine how much of the benefits were from walking and how much was from increased encouragement. Either way, Brown’s experience with patients, from physical therapist to geriatrician, is moving not only patients forward in their care, but the field of geriatrics itself.