A team of researchers from Ohio State University’s College of Nursing recently received a $1.6 million federal grant to try to reduce the chances of young, Black adults getting heart disease.
Researchers from Vanderbilt University and The Ohio State University are teaming up to develop next-generation robotic technology that can help older adults living with forms of dementia through a grant from the National Institute on Aging (NIA) at the National Institutes of Health (NIH). The five-year grant, totaling $3.13 million, will support research and development of robotic framework and methodologies that encourage social interaction among older adults in long term care (LTC) facilities like nursing homes and independent or assisted living facilities.
Social interaction is known to produce positive health benefits among older adults suffering from cognitive impairments including the progression to Alzheimer’s and related dementias. Conversely, without social interaction, older adults may fall victim to apathy and its ripple effects of loneliness, social isolation and cognitive decline, not to mention the stress and frustration experienced by caregivers. The effects of apathy – the lack of feeling or emotion – among the aging also manifest in the decline of physical health. The stress and anxiety that apathy can produce negatively alters heart health and blood pressure, leading to increased mortality.
Currently, 72% of all adults in LTC facilities experience apathy.
While its necessity has been made clear, there are not enough skilled or well-resourced caretakers to facilitate the kind of social interaction that the growing population of aging adults needs to thrive. By 2034, and for the first time in U.S. history, older adults (people age 65 and older) will outnumber children under age 18, presenting an impending reality that will need to be accommodated.
To address a growing population and work around the limits of caretakers and to capitalize on burgeoning technology, Nilanjan Sarkar, David K. Wilson Professor of Engineering, chair of the Department of Mechanical Engineering and professor of mechanical and computer engineering and a multidisciplinary team of engineers, nurses, physicians and health services researchers from Vanderbilt and The Ohio State Universities explore new opportunities in robotics to facilitate social interaction between aging adults.
Sarkar’s project will be conducted jointly with Lorraine Mion, professor of nursing at The Ohio State University and former Independence Foundation Professor in nursing at the Vanderbilt School of Nursing. It will explore how socially assistive robots (SARs) – a type of assistive robot designed specifically for social interactions and capable of autonomously detecting and meaningfully responding to older adults’ attention and behavior – can effectively target and engage older adults with Alzheimer’s Disease and related cognitive impairments in LTC environments. Paul Newhouse, Jim Turner Professor of Cognitive Disorders and professor of psychiatry and behavioral sciences, pharmacology, and medicine at Vanderbilt University Medical Center is also a co-Investigator for this project.
“We aim to create a better quality of life for the aging population of our society,” said Sarkar, also Director of the Robotics and Autonomous Systems Lab (RASL). “While there is no cure for dementia at this point, research shows that if we can keep people mentally engaged and active, we can possibly slow the progression of the disease and the deterioration of their overall health. Our research will help us understand how to create robots to act as a coach as well as a peer to facilitate interpersonal connections in a sustainable, meaningful way.”
“We know from research that apathy is the most common neuropsychiatric symptom in older adults with dementia and can have dire effects on both the quality of life for the patient and the emotional stability of the caregiver,” said Mion. “What we are seeking to understand is how we can improve engagement strategies using advanced-but-user-friendly robotic systems to stave off apathy and improve lives for these older adults in long-term care facilities.”
The study builds off Sarkar and Mion’s recently concluded Exploratory Research (R21) grant (NIA:1R21AG050483-01A1) during which they created and deployed Adaptive Robot-mediated Intervention Architecture (ARIA) to promote social interaction vis a vis specialized tasks that depend on human interaction and collaboration.
The foundational study will enable the researchers to address three specific aims in their current research: to improve ARIA through additional software development, to measure a reduction in apathy among older adults with cognitive impairments and mild or moderate dementia, and to identify future scalability and sustainability of SAR implementation in LTC settings.
COLUMBUS, OH— The National Institutes of Health/National Cancer Institute (NIH/NCI) has awarded a five-year career development grant to Principal Investigator Timiya S. Nolan, PhD, APRN-CNP, ANP-BC, assistant professor in the College of Nursing’s Martha S. Pitzer Center for Women, Children and Youth and her team to fund the study, “Piloting Y-AMBIENT: A Quality of Life Intervention for Young African American Breast Cancer Survivors in Treatment.”
Mentors on the study, all from Ohio State, include: Darryl D. Hood, PhD, College of Public Health; Electra D. Paskett, PhD, College of Medicine; Barbara Andersen, PhD, College of Psychology; Maryam Lustberg, MD, MPH, The James Comprehensive Cancer Center; and Alai Tan, PhD, College of Nursing. Mentors will guide Nolan in her pursuit of building an independent program of research that identifies contextual factors of quality of life (QOL) among young (18-44) breast cancer survivors from underrepresented minority groups.
In addition to training, this grant will support a study aimed at evaluating processes and preliminary outcomes of a targeted QOL intervention compared to enhanced usual care intervention in young African American (AA) cancer survivors who are receiving treatment for early (I-II) and late (III) stage breast cancer.
In this study, Nolan and her team will recruit and randomize 40 young AA breast cancer survivors who are in primary breast cancer treatment to an intervention group. This population is targeted given their general report of poorer QOL and more negative social determinants of health (e.g., low socioeconomic status, limited access to care, discrimination) than young White survivors.
The team will triangulate qualitative and quantitative responses from each participant to identify perceptions of the study’s feasibility and acceptability, chiefly measured by willingness to participate and the use of self-management strategies prescribed in the interventions. The team will also examine health-related outcomes (i.e., QOL, spiritual well-being, self-efficacy and social support) within and between intervention groups.
Upon completion of the study, the team will look to perform a larger, randomized controlled trial to determine efficacy and translate its findings to inform the development, implementation and dissemination/translation of multi-level QOL interventions and policy changes.
“This grant is building the foundation of my research career aimed at building healthy communities,” said Nolan. “My Y-AMBIENT intervention was adapted by applying the voices and stories of young AA breast cancer survivors. This pilot study will give us an indication of how my targeted intervention compares to enhanced usual care in these women, showing us the way forward to reduce disparities in cancer survivorship.”
“I’m ecstatic and honored to be trusted with this award,” said Nolan. “We at The Ohio State University believe that everyone deserves their best chance at living and living well, and ultimately this training and study will give me the tools to play my part as the change agent who helps cancer survivors attain wellness in their ‘new normal.’”
A continuing NIH T32 training grant awarded to The Ohio State University College of Nursing from the National Institutes of Health/National Institute of Nursing Research (NIH/NINR) will support the training of pre-doctoral students studying health development across the life course. PhD students in nursing will conduct research while working closely with 24 faculty from nursing, sociology, emergency medicine and pediatric medicine. Each year for the next five years, two or three newly admitted nursing PhD students will be supported over two or three years. Our first trainees will start in the 2020–2021 academic year. This novel training program has four goals to address fundamental challenges in nursing research today:
- recruit and retain diverse and qualified pre-doctoral trainees to conduct rigorous research in the science of health development
- prepare trainees to develop and implement ethical health research in the science of health development
- provide scientific grounding and research experiences with highly qualified faculty and using extensively available resources to prepare trainees for research careers
- increase the number and strengthen the scientific foundation of early career nurse scientists
Central to the training plan is the broadening of our PhD program focus on health determinants, incorporating a modification of the ecodevelopmental and life course model. In light of how health develops across the life course, the research community is challenged to stimulate new research, to develop creative solutions for improving health and wellness and to translate research findings into social policy that will optimize health. This renewal includes attention to sensitive periods of health development from preconception to old age. Trainees will be prepared to lead research teams based upon a life course health development framework that considers the intersection of determinants of health with human biological, psychological, and epigenetic processes, and explains the mechanisms and wellness outcomes of this interaction. The program will further NINR’s goal to support research on the science of health and wellness, which is integral to NINR’s mission as well as across the NIH and the entire federal government, all of whom have recognized that improving health and well-being is critical to reducing the burden of illness now and in the future.
Class of 2020–2021 trainees (advisors): Nicole Cistone (Pickler, Fortney), Emika Miller (Happ), Lindsay Smith (Harrison)
The first T32 was funded in 2013. Nine trainees have or will complete the program: Lisa Blair (2018), Colleen McGovern (2018), Randi Bates (2019), Marliese Nist (2019), Elizabeth Hutson (2020), Emma Schlegel, Alexandra Nowak, Stephanie Sealschott, and Laura Beth Kalvas.
Application for The Nursing PhD program for fall 2021 will open in August 2020. The deadline for the submission of all application materials is January 4, 2021. To learn more about our PhD program, please visit our website.
The National Institutes of Health/National Institute of Nursing Research (NIH/NINR) has awarded a four-year, $1.6 million R01 grant to fund the study, “Reducing Cardiovascular Risk Factors in Black Young Adults.” The grant was awarded to Janna Stephens, PhD, RN, (PI) assistant professor at The Ohio State University College of Nursing’s Martha S. Pitzer Center for Women, Children and Youth. Co-investigators from Ohio State include Bernadette Melnyk, PhD, APRN-CNP, EBP-C, FAANP, FNAP, FAAN, and Alai Tan, PhD, of the College of Nursing and Carla Miller, PhD, of the College of Public Health. Other co-investigators include Lora Burke, PhD, of Pittsburgh University and Antoinette Perkins of Columbus State Community College.
The study focuses on developing strategies and interventions to assist young African American adults who attend community colleges in creating and sustaining improved health habits in order to reduce the risk of cardiovascular issues later in life.
Stephens and her team will recruit 256 African American community college students who are overweight or obese for the study. This understudied population is at very high risk for cardiovascular disease later in life.
Their goal is to provide these students with a personalized, culturally tailored health coaching program to promote heathy eating and increased exercise habits. During one year, Stephens and her team will track students via a smartphone application, conduct health coaching sessions and provide resources and information to help them eat healthily, increase physical activity and develop other health habits to achieve health, fitness and weight loss goals.
“I really enjoy working with the community college population and making connections with these at-risk students,” said Stephens. “I cannot wait to start working with my team and the students to teach them healthy lifestyle habits to prevent cardiovascular disease later in life!”
When researchers asked prospective study participants who they would like to see in videos promoting healthy lifestyle behaviors, the answer was unequivocal: They wanted to see themselves – that is, other mothers living in low-income households who were overweight or obese.
The researchers obliged. And the intervention they designed produced the desired results when it came to improving participants’ diet. As a group, the women in the study who watched the videos and talked to their peers over 16 weeks were more likely to have reduced their fat consumption than women in a comparison group who were given print materials about lifestyle change.
The participants were women who face stubborn health challenges – highly stressed overweight low-income mothers of young children who, for example, tend to retain 10 or more pounds of pregnancy weight after childbirth and are likely to eat high-fat foods. They are at risk for life-long obesity and potential problems for themselves and new babies if they become pregnant again.
“I asked them during focus groups who should be in the videos, and they said, ‘We want to see us. And our children. Do not lie to us and hire professionals, because we’ll be able to tell,’” said Mei-Wei Chang, lead author of the study and associate professor of nursing at The Ohio State University.
“They said, ‘We want to see them before the change and the struggles they had, and what happened after that.’”
Chang and colleagues identified two factors that led to the intervention’s success: The study was designed to appeal to the participants’ personal values and instill in these mothers enough confidence to take on the challenge of living a healthier life.
“My experience with this population is that they really want to make a change. Some might perceive that they don’t want to. But they do – they just don’t know how to,” Chang said.
The research is published online in the journal Appetite and will appear in the August print issue.
The two psychosocial factors Chang and colleagues examined in this study are known as autonomous motivation (what’s important in a person’s life) and self-efficacy (a person’s confidence in her ability to carry out a behavior or task). Previous research has shown that poverty can lead to low self-efficacy.
Autonomous motivation differs by population. In this study, the participants told researchers in focus groups before the intervention began that they wanted to be role models for their children. They hoped to be less stressed and happier, and to maintain good family relationships.
Chang recruited participants from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which serves low-income pregnant, postpartum and breastfeeding women and children up to age 5. Those eligible for the program must have an annual household income no higher than 185 percent of the federal poverty line.
The mothers were between the ages of 18 and 39 and their body mass index ranged from 25.0 to 39.9 – from the lowest indicator of being overweight to just below the extreme obesity range. The intervention was aimed at preventing weight gain by promoting stress management, healthy eating and physical activity. This study analyzed only the diet-related results.
During the trial, the 212 participants randomized into the intervention group watched a total of 10 videos in which women like them gave testimonials about healthy eating and food preparation, managing their stress and being physically active.
In the videos, the women wore casual clothes and told their stories, unscripted. They demonstrated meal prep with familiar foods and showed that simple, practical steps – like reading food labels – could gradually lead to a healthier lifestyle.
“They talked about a lot of things I didn’t know,” said Chang, who has worked with women enrolled in WIC for about 20 years. “They spoke their mind about what was important – like how they mentally dealt with changing behavior but not losing weight. And about being afraid to fail.”
The participants also dialed in to 10 peer support group teleconferences over the course of the study.
In phone interviews, the researchers asked the mothers about what they were eating, their confidence in sticking to a low-fat diet and why they wanted to eat more healthfully.
Based on those surveys, the researchers determined that, compared to the group reading print materials, the mothers who watched videos and spoke with their peers reported larger increases in autonomous motivation and self-efficacy and a more significant decrease in fat intake after the 16-week intervention.
“Essentially, they said, ‘If she could do it, I could do it.’ That’s why we used peers to develop the intervention,” Chang said.
The researchers are still analyzing data related to physical activity results, and have found that the intervention’s emphasis on coping self-efficacy helped reduce participants’ stress. The videos are now part of WIC’s continuing education series for mothers.
This work was supported by the National Institutes of Health.
Co-authors included Alai Tan and Duane Wegener from Ohio State and Jiying Ling and Lorraine Robbins from Michigan State University.
College ranks #16 among all nursing colleges, #9 among public institutions
The Ohio State University College of Nursing has strengthened its standing as a top earner of grant funding from the National Institutes of Health (NIH). The Blue Ridge Institute for Medical Research’s new review of NIH grant awards ranks the College of Nursing at #16 overall and #9 among public institutions, with approximately $4.3 million in NIH research funding.
This is the third consecutive year that the College of Nursing has ranked in the nation’s top 20 for primary NIH grant funding. Overall, the college received approximately $10.7 million in research and development grants from external funders, including NIH, in FY2019.
“Our standing as a premier research college is driven by the passion, innovation and dedication of our research leadership, faculty and staff to improve healthcare quality and health outcomes,” said Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN, vice president for health promotion, university chief wellness officer and dean of the College of Nursing. “The NIH’s continued investment in our research helps us transform health and improve lives by dreaming, discovering and delivering a healthier world.”
“The innovative and relevant science that our research faculty conduct is addressing critically-important healthcare problems,” said Mary Beth Happ, PhD, RN, FGSA, FAAN, associate dean for research and innovation at the College of Nursing. “Their work will help improve the health and well-being of people across the life-span.”
This round of NIH funding encompasses both new awards and recurrent years of funding for existing, supported research programs. New awards for the College of Nursing support science in the area of aging, including pain/symptom management and interventions to promote cognitive and functional recovery from critical illness in adults. Those programs include:
Expansion of study on pain differences for Alzheimer’s patients
Karen O. Moss, PhD, RN, CNL, assistant professor at the College of Nursing, received a diversity supplement award in conjunction with a five-year existing NIH/National Institute on Aging (NIA) study entitled “Sex Differences in Pain Reports and Brain Activation in Older Adults with Alzheimer’s Disease.” The grant was awarded to an interdisciplinary team that includes Todd Monroe, PhD, RN-BC, FNAP, FGSA, FAAN, associate professor in College of Nursing, as well as faculty from the College of Nursing, the Departments of Neurology and Geriatrics, the Wright Center of Innovation in Biomedical Imaging at Ohio State and collaborators from Vanderbilt University. The study is examining gender and Alzheimer’s-related differences in verbal pain reporting patterns and how they are displayed in regional and network brain function, with an aim to lead to better pain management. Moss’ work will focus on how patients of different racial backgrounds self-report pain and the impact of Alzheimer’s on how the brain processes pain, with the long-term goal of developing appropriate interventions.
Advancing science on sensitivity to cancer pain in Alzheimer’s patients
Monroe and his research partner Ronald Cowan, MD, PhD, professor of psychiatry and behavioral health at Vanderbilt University, will lead a multi-site five-year, $5 million NIH/NIA grant project to advance research focused on patients with Alzheimer’s disease and certain types of cancer and their sensitivity to pain. The study, “Pain Sensitivity and Unpleasantness in People with Alzheimer’s Disease and Cancer,” examines whether these patients are at greater risk of suffering from poorly-treated pain at the end of life.
Helping adults needing treatment in intensive-care units
The National Institutes of Health/National Heart, Lung and Blood Institute (NIH/NHLBI) awarded a three-year, $1.2 million grant to Michele Balas, PhD, RN , CCRN-K, FCCM, FAAN, associate professor in the College of Nursing. The study entitled “Determinants of Implementation Success Coordinating Ventilator, Early Ambulation and Rehabilitation Efforts in the ICU (DISCOVER-ICU)” includes collaborators Alai Tan, PhD, (Co-I) and Lorraine Mion, PhD, RN, FAAN, (Co-I) of The Ohio State University College of Nursing, plus collaborators from Vanderbilt University and the Society of Critical Care Medicine. This study advances research into evidence-based interventions – including what is known as the ABCDEF bundle – to improve clinical outcomes in ICU patients.
NIH/NIA also awarded a two-year, $312,000 grant to fund the study, “A Problem Solving Intervention for Post-ICU Cognitive Impairment in Older Adults.” The grant was awarded to Judith Tate, PhD, RN (PI), assistant professor in The Ohio State University College of Nursing. Co-investigators include Lorraine C. Mion, PhD, RN, FAAN, and Alai Tan, PhD, of the College of Nursing, and Jennifer Bogner, PhD, ABPP, FACRM, of the Department of Physical Medicine and Rehabilitation in the College of Medicine. This pilot study focuses on the risks of delirium to brain health in older patients treated in ICUs and tests the impact of a home-based intervention.
NIH-supported research also continues on multi-year grants already awarded to faculty working in the Martha S. Pitzer Center for Women, Children and Youth. That research includes:
- Tondi Harrison, PhD, RN, FAAN: Examining responses to oral feeding in infants with both Down syndrome and congenital heart disease
- Shannon Gillespie, PhD, RN: Testing a novel method of identifying women at risk for inflammatory preterm birth and how specific preventive interventions may offer benefit during pregnancy
The College of Nursing is currently hiring new faculty who are committed to transforming health and improving lives. You can find job openings in the college by clicking on this link.
New five-year, $5 million grant project to advance study on sensitivity to pain
COLUMBUS, Ohio – Todd Monroe, PhD, RN-BC, FNAP, FGSA, FAAN, associate professor at The Ohio State University College of Nursing, will help lead a multi-site five-year, $5 million grant project awarded by the National Institutes of Health (NIH) and National Institute on Aging (NIA) to advance research focused on patients with Alzheimer’s disease and cancer and their sensitivity to pain.
“This grant will study the response to experimentally-evoked thermal and pressure pain to determine if people with chronic cancer pain and Alzheimer’s disease may be at greater risk of suffering from poorly-treated pain at the end of life,” Monroe said. “This is especially important for patients with Alzheimer’s disease who also have cancers, such as prostate and breast cancer, that generally lead to very painful bone metastasis.”
The multi-site, multiple PI R01, Pain Sensitivity and Unpleasantness in People with Alzheimer’s Disease and Cancer, will be performed in close partnership with Ronald Cowan, MD, PhD, Professor of Psychiatry and Behavioral Health from Vanderbilt University. The research builds on numerous studies that Monroe and his colleagues have conducted over the last decade, including research that concluded that patients living with more severe dementia and cancer were at greater risk for not receiving hospice services and for receiving little or no pain medication during the end of life. Last year, Monroe and his team earned a five-year, $3.3 million NIH/NIA grant to examine gender and Alzheimer’s-related differences in verbal pain reporting patterns and how they are displayed in regional and network brain function, with an aim to lead to a better understanding of how Alzheimer’s and gender impact central pain mechanisms.
Monroe, Cowan and their team hope to use the information from this research to further explore the neurobiology of pain in older adults with dementia and chronic pain, which can in turn help lead to the development and testing of interventions to better manage pain in this growing population.
Grants support transformative research in healthcare across the lifespan
The Ohio State University College of Nursing announced today that faculty researchers at the college received approximately $10.7 million in grant funding during fiscal year 2019. That compares to $6.9 million granted for fiscal year 2018.
This level of funding supports research in several critical areas of healthcare, including aging and dementia care, understanding and preventing preterm birth, health and wellness interventions for vulnerable populations, symptom science, and improving critical and chronic care outcomes across the lifespan.
“We are grateful for the support our research faculty continue to receive to advance nursing and health sciences,” said Mary Beth Happ, PhD, RN, FAAN, FGSA, associate dean of research and innovation at the College of Nursing. “Our researchers pursue breakthroughs and provide leadership in priority areas that promote wellness, stunt the impact of chronic disease and improve health across the lifespan.”
The college revealed in February that last year, it ranked #13 overall and #6 among public institutions nationally in National Institutes of Health (NIH) grant funding specifically.
The National Institutes of Health/National Heart, Lung and Blood Institute (NIH/NHLBI) has awarded a three-year, $1.2 million R01 grant to Michele Balas, PhD, RN , CCRN-K, FCCM, FAAN, associate professor in The Ohio State University College of Nursing. This R01 will fund a research study entitled, “Determinants of Implementation Success Coordinating Ventilator, Early Ambulation and Rehabilitation Efforts in the ICU (DISCOVER-ICU).” Collaborators on the grant include Alai Tan, PhD, (Co-I) and Lorraine Mion, PhD, RN, FAAN, (Co-I) of The Ohio State University College of Nursing; Brenda T. Pun, DNP, RN (Co-I), Eduard E. Vasilevskis, MD, MPH, FHM (Co-I), and E. Wesley Ely, MD, MPH (consultant), of Vanderbilt University; and Lori A. Harmon, RRT, MBA (Co-I), of the Society of Critical Care Medicine.
“This study addresses the need to improve the care and outcomes of the millions of patients admitted to U.S. intensive care units (ICUs) annually,” Balas stated. “Persons experiencing an illness severe enough to require an ICU stay frequently experience profound physical, mental and cognitive health impairments that may persist for months to years after hospital discharge.
“Evidence demonstrates these clinical outcomes improve when integrated, interprofessional, evidence-based approaches to symptom management, mechanical ventilation and physical mobility are applied,” Balas continued. “One such approach, the ABCDEF bundle, has been associated in previous studies with lower ICU and hospital mortality rates, fewer days spent on mechanical ventilation, fewer days spent in physical restraints and lower odds of delirium and coma. Despite these proven benefits, the ABCDEF bundle has yet to be widely adopted in everyday ICU care.”
In the NIH-funded study, Balas and her team will continue their three-year partnership with the Society of Critical Care Medicine’s ICU Liberation Collaborative. The overall objective of the research is to develop multilevel implementation strategies to enhance sustainable adoption of the ABCDEF bundle in routine ICU practice. The team is particularly interested in discovering how various patient-, provider-, and organization-level characteristics and implementation strategies effect ABCDEF bundle adoption.
The results of this work aim to lead directly to the development of implementation strategies that are adaptable, responsive to the needs of the critical care community and accountable for the cultural and organizational factors necessary to increase ABCDEF bundle adoption.
“Our team is thrilled to lead this important line of investigation. We firmly believe that better integration of the evidence-based ABCDEF bundle has the potential to substantially reduce the short- and long-term physical, cognitive and emotional burden critical illness imposes on critically ill adults and their family members.”
Tate awarded NIH/NIA grant
The National Institutes of Health/National Institute on Aging (NIH/NIA) has awarded a two-year, $312,000 grant to fund the study, “A Problem Solving Intervention for Post-ICU Cognitive Impairment in Older Adults.”
The grant was awarded to Judith Tate, PhD, RN (PI), assistant professor in The Ohio State University College of Nursing. Co-investigators include Lorraine C. Mion, PhD, RN, FAAN, and Alai Tan, PhD, of the College of Nursing, and Jennifer Bogner, PhD, ABPP, FACRM, of the Department of Physical Medicine and Rehabilitation in the College of Medicine. The grant will run from April 15, 2019, to March 31, 2021.
“Older adults comprise more than half of all intensive care unit (ICU) days and are at risk of delirium, a common acute brain impairment associated with increased risk for dementia and altered trajectories of cognitive recovery,” the grant proposal states. “The purpose of this pilot study is to evaluate the feasibility, acceptability and early efficacy of a problem-solving intervention, Post Intensive Care Unit Problem Solving (PIC-UPS) in the home setting for older adult ICU survivors suffering from post-ICU cognitive impairment.”