Publications

Abstract

Background: Diet and nutrition management is an integral component of Crohn disease (CD) management. This type of management is highly variable and individualized and, thus, requires personalized approaches. Consumer health information technology (CHIT) designed to support CD management has typically supported this task as everyday life work and, not necessarily, as illness work. Moreover, CHIT has rarely supported the ways in which diet and nutrition management requires coordination between multiple forms of patient work. Objective: The purpose of this study was to investigate diet and nutrition management as biform work, identify components of articulation work, and provide guidance on how to design CHIT to support this work. Methods: We performed a qualitative study in which we recruited participants from CD-related Facebook pages and groups. Results: Semistructured interviews with 21 individuals showed that diet and nutrition management strategies were highly individualized and variable. Four themes emerged from the data, emphasizing the interactions of diet and nutrition with physical, emotional, information, and technology-enabled management. Conclusions: This study shows that the extent to which diet and nutrition management is biform work fluctuates over time and that articulation work can be continuous and unplanned. The design guidance specifies the need for patient-facing technologies to support interactions among diet and nutrition and other management activities such as medication intake, stress reduction, and information seeking, as well as to respond to the ways in which diet and nutrition management needs change over time.

Abstract

The ever-evolving composition of the U.S. population prompts healthcare systems to adapt in order to provide care to diverse populations. Health disparities exist, and it is part of our responsibility as medical professionals to reflect on how the sociocultural determinants of health affect outcomes and uncover our unconscious or implicit biases to work towards health equity. The author defines this process as cultural praxis, drawing from Freire’s theory on developing a critical consciousness and understanding cultural humility. Physicians must also understand the systematic problems that lead to inequities in healthcare; the author defines this as structural competence. As in professional identity formation, development of a critical consciousness is an ongoing process that requires reflection, and cultural praxis is more than a set of competencies to be satisfied. This discusses strategies for developing cultural praxis, and provide reflective opportunities in scenarios in which cultural praxis is particularly important, such as in end-of-life care.

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Background: The COVID-19 pandemic has resulted in a profound transformation of health care delivery toward telemedicine models. Purpose: We present the structure of a nurse-led telephonic palliative program and operational metrics to influence further development of tele-palliative programs. Methods: The nurses engage with seriously ill patients for 6 months with the goal of discussing advance care planning (ACP) and addressing self-identified issues related to their illness. Findings: Of the first 100 program graduates, 78% were actively engaged and 51% named a health care agent and/or engaged in ACP. Of the 18 patients who died during the study, 13 (72%) were enrolled in hospice services. Discussion: Our preliminary results indicate that seriously ill patients are willing to engage with nurses and to participate with discussions on ACP. Conclusion: Given the gaps in health care exposed by the COVID-19 pandemic, this innovative program serves as an important model for bringing palliative care directly to patients.

Abstract

In this chapter, the revised Network Episode Model (NEM) as the basis for a situation-specific theory that provides an explanation of how Malawian women come to make a decision about and act to obtain cervical cancer screening. The situation-specific theory takes into account the uniqueness of Malawian women's individual factors, interpersonal relationships factors, and sociocultural factors. The theory emphasizes the need to attend to the unique factors that influence cervical cancer screening behaviors of women in their unique situations.

Abstract

Patients with diabetes mellitus may experience painful and nonpainful diabetic peripheral neuropathy (DPN). This article offers an overview of DPN and the clinical assessment and management of patients with DPN, as well as the nurse's role in supporting these patients.

Abstract

Objectives: Despite increased risk for chronic disease, there is limited research that has examined disparities in multimorbidity among sexual minority adults and whether these disparities differ by age. Methods: Data were from the 2014–2018 Behavioral Risk Factor Surveillance System. We used sex-stratified multinomial logistic regression to examine differences in multimorbidity between sexual minority and heterosexual cisgender adults and whether hypothesized differences varied across age-groups. Results: The sample included 687,151 adults. Gay, lesbian, and bisexual adults had higher odds of meeting criteria for multimorbidity than same-sex heterosexual adults. These disparities were greater among sexual minority adults under the age of 50 years. Only other non-heterosexual men over the age of 50 years and lesbian women over the age of 80 years were less likely to have multimorbidity than their same-sex heterosexual counterparts. Discussion: Health promotion interventions to reduce adverse health outcomes among sexual minorities across the life span are needed.

Abstract

BACKGROUND: There is limited research on hypertrophic cardiomyopathy (HCM), which is the most common inherited cardiac disorder, in diverse populations, including Black individuals. Current literature lacks comprehensive data on HCM disease expression, comorbidities, and outcomes in this historically disadvantaged group. The purpose of this study was to examine structural HCM characteristics, comorbidities, and outcomes in a Black and White cohort with HCM. METHODS AND RESULTS: The study was a subgroup analysis from a longitudinal, prospective study on HCM, with supplemental chart review. The sample included adults (≥18 years) with a clinical diagnosis of HCM, who self-identified as Black/African American or White. The study sample comprised 434 individuals; 57 (13.1%) were Black, and 180 (41.5%) were women. Black patients were younger than White patients, 54.6 (13.4) versus 62.5 (14.8) years, P=0.001. Black patients were more likely to have sub-basal and diffuse hypertrophy, 22 (38.6%) versus 56 (14.9%), P<0.001, 6 (10.5%) versus 15 (4%), P=0.017, mid-LV obstruction, 7 (12.3%) versus 21 (5.5%), P=0.025, and cardiac fibrosis ≥15%, 10 (22.2%) versus 19 (8.8%), P=0.009, than White patients. Black patients were more likely to experience appropriate implantable cardioverter defibrillator interventions, 5 (38.5) versus 5 (6.8), P<0.001 and were more likely to have ≥2 sudden death risk factors. Comorbidities were largely similar between groups, though more Black participants had Class II obesity, 12 (21.8) versus 30 (8.1), P<0.001. Both groups had similar rates of genetic testing usage. CONCLUSIONS: This study underscores the need for continued research of HCM in Black populations, including tailored approaches to diagnosis and precise evaluation of cardiac anatomy.

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Background: Disparities in breastfeeding patterns by race and ethnicity in the United States have been documented, and Latinx ethnicity is often associated with higher rates of breastfeeding initiation and longer breastfeeding duration compared to other U.S. racial and ethnic groups. Despite marked differences in infant feeding practices in Latinx countries of origin, U.S. breastfeeding data are routinely presented with Latinx as a single category. Objective: To analyze breastfeeding duration of New York City Latinx mothers by birth region. Methods: Using data from the 2016 New York City Work and Family Leave Survey (WAFLS) surveying residents who gave birth in 2014, we conducted a survival analysis of breastfeeding duration in a sample of Latinx-identifying mothers (n = 271), who reported having ever breastfed their child. Kaplan-Meier survival curves for time to breastfeeding cessation were created for four birth regions (United States, Caribbean, Mexico/Central America, and South America) and compared using the log-rank test. Adjusted hazard ratios (AHRs) were calculated using Cox regression. Results: Survival curves and median breastfeeding duration were significantly different between the four regions. AHR models found that non-Caribbean birthplace was significantly associated with a lower risk of early breastfeeding cessation. Being partnered at the time of childbirth and neonate hospitalization of 6 days or longer was associated with a greater risk of earlier breastfeeding cessation. Conclusion: The significant differences reinforce the need to separate breastfeeding findings by birth region in the Latinx population. Within-group differences are lost in combined analyses and reinforce conclusions that Latinx mothers have optimal breastfeeding behaviors.

Abstract

Purpose of review The purpose of this review was to assess the prevalence of United States chronic kidney disease (CKD) health disparities, focusing on racial/ethnic groups, immigrants and refugees, sex or gender, and older adults. Recent findings There are major racial/ethnic disparities in CKD, with possible contributions from the social determinants of health, socioeconomics, and racial discrimination. Racial/ethnic minority patients experience faster progression to end-stage kidney disease (ESKD) and higher mortality predialysis, however, once on dialysis, appear to live longer. Similarly, men are quicker to progress to ESKD than women, with potential biological, behavioral, and measurement error factors. There is a lack of substantial evidence for intersex, nonbinary, or transgender patients. There are also strikingly few studies about US immigrants or older adults with CKD despite the fact that they are at high risk for CKD due to a variety of factors. Summary As providers and scientists, we must combat both conscious and unconscious biases, advocate for minority patient populations, and be inclusive and diverse in our treatment regimens and provision of care. We need to acknowledge that sufficient evidence exists to change treatment guidelines, and that more is required to support the diversity of our patient population.

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OBJECTIVE: To determine if Black nurses are more likely to report job dissatisfaction and whether factors related to dissatisfaction influence differences in intent to leave. BACKGROUND: Minority nurses report higher job dissatisfaction and intent to leave, yet little is known about factors associated with these differences in community settings. METHOD: Cross-sectional analysis of 11 778 nurses working in community-based settings was conducted. Logistic regression was used to estimate the association among race, job satisfaction, and intent to leave. RESULTS: Black nurses were more likely to report job dissatisfaction and intent to leave. Black nurses' intent to leave decreased in adjusted models that accounted for dissatisfaction with aspects of their jobs including salary, advancement opportunities, autonomy, and tuition benefits. CONCLUSION: Nurse administrators may find opportunities to decrease intent to leave among Black nurses through focused efforts to target areas of dissatisfaction.

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Homebound older adults are a highly vulnerable population, yet little is known about their experiences with healthcare during the COVID-19 pandemic. We interviewed patients in home-based primary care (HBPC) in New York City by telephone in May and June of 2020. Interviews covered social supports, household activities, self-care, and medical care, and asked participants to compare current with prepandemic experiences. Among 70 participants, 37% were Black and 32% were Hispanic. Disruptions in the home included greater difficulty accessing paid caregivers (13.9%) and food (35.3%) than before the pandemic, and unaddressed household chores (laundry, 81.4%; food preparation, 11.4%). Black study participants were more likely than White and Hispanic participants to report disruptions in accessing medical care (13 [50.0%] vs. 3 [14.3%] vs. 6 [27.3%], respectively, p = 0.02), as well as food preparation and medication taking. Black patients in HBPC are at risk of disparities in healthcare and social support during the COVID-19 pandemic.

Abstract

Creating effective programs for cervical cancer prevention is essential to avoid premature deaths from cervical cancer. The Dominican Republic has persistently high rates of cervical cancer, despite the availability of Pap smear screening. This study explored Dominican provider attitudes towards human papillomavirus (HPV) testing and current challenges to effective cervical cancer prevention. In this Consolidated Framework for Implementation Research (CFIR)–driven mixed methods study, we conducted in-depth interviews (N = 21) and surveys (N = 202) with Dominican providers in Santo Domingo and Monte Plata provinces regarding their perspectives on barriers to cervical cancer prevention and their knowledge and attitudes towards HPV testing as an alternative to Pap smear. Providers believed the main barrier to cervical cancer prevention was lack of cervical cancer awareness and resulting inadequate population screening coverage. Providers felt that Pap smear was widely available to women in the Dominican Republic and were unsure how a change to HPV testing for screening would address gaps in current cervical cancer screening programs. A subset of providers felt HPV testing offered important advantages for early detection of cervical cancer and were in favor of more widespread use. Cost of the HPV test and target age for screening with HPV testing were the main barriers to acceptability. Providers had limited knowledge of HPV testing as a screening test. The group was divided in terms of the potential impact of a change in screening test in addressing barriers to cervical cancer prevention in the Dominican Republic. Findings may inform interventions to disseminate global evidence-based recommendations for cervical cancer screening.

Abstract

Cervical cancer is the second leading cause of cancer death for women in the Dominican Republic. Pap smear screening in the Dominican Republic has not achieved adequate reduction in cervical cancer mortality. The purpose of this study was to examine Dominican provider practices for cervical cancer screening and the use of national or international screening guidelines. We surveyed 101 gynecology specialists, 50 non-specialists, and 51 obstetrics-gynecology residents in the Santo Domingo and Monte Plata provinces of the Dominican Republic regarding their cervical cancer screening practices and use of guidelines. Bivariate (chi-square) analyses were conducted to compare screening practices by demographic and practice characteristics. The majority of providers followed WHO guidelines (62.9%) and/or Dominican national norms (59.4%). The majority (87%) of providers use time since first sexual activity as the basis for screening initiation; 96% advise screening every 6–12 months. The most commonly used screening test is the conventional Pap smear. Colposcopy was recommended most often for all abnormal Pap results. Dominican providers report they follow national and/or international cervical cancer screening guidelines. They do not follow age-based screening guidelines, nor have they adopted an extended interval for screening and continue to recommend screening at least annually. A culture of early and frequent screening has consequences in terms of cost, high demand for follow-up services, and reduced capacity to reach the populations at highest risk. Early screening also may challenge the acceptability of adopting alternative screening technologies such as HPV testing.

Abstract

Objectives: To quantify the dose-response associations between tooth loss and risk of cognitive impairment and dementia. Design: Longitudinal studies that examined the association between tooth loss and cognitive function were systematically searched on 6 databases through March 1, 2020. The study adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Risk estimates were pooled using random-effects models. The dose-response associations were assessed using generalized least squares spline models. Setting and Participants: Adults from community, institution, outpatient or in-hospital were included in the meta-analysis. Measures: Cognitive impairment and dementia were defined by neuropsychological tests, diagnostic criteria, or medical records. Tooth loss was self-reported or assessed by clinical examinations. Results: Fourteen studies were entered into the meta-analysis, including 34,074 participants and 4689 cases with diminished cognitive function. Participants with more tooth loss had a 1.48 times higher risk of developing cognitive impairment [95% confidence interval (CI) 1.18–1.87] and 1.28 times higher risk of being diagnosed with dementia (95% CI 1.09–1.49); however, the association was nonsignificant for participants using dentures (relative risk = 1.10, 95% CI 0.90–1.11). Eight studies were included in the dose-response analysis, and data supported the use of linear models. Each additional tooth loss was associated with a 0.014 increased relative risk of cognitive impairment and 0.011 elevated relative risks of dementia. Edentulous participants faced a 1.54 times higher risk of cognitive impairment and a 1.40 times higher risk of being diagnosed with dementia. Conclusions and Implications: Moderate-quality evidence suggested tooth loss was independently associated with cognitive impairment and dementia; risk of diminished cognitive function increased with incremental numbers of teeth lost. Furthermore, timely prosthodontic treatment with dentures may reduce the progression of cognitive decline related to tooth loss.

Abstract

To educate nursing students and practicing registered nurses about population health management (PHM), a team of faculty and PHM clinical leaders created an innovative, scalable, turnkey ready, multimedia e-learning module. The module has four lessons; takes approximately three hours to complete; and can be accessed using a weblink from computers, smart phones, and tablets. The module engages learners with videos, flashcards, case studies, and a variety of interactive knowledge checks. Each learner can obtain a record of completion, which can be shared with faculty. Faculty implemented the module with 48 senior prelicensure nursing students who reported improved self-efficacy in PHM.

Abstract

Aim: The objective of this systematic review was to summarize the ecological momentary assessment (EMA) methodology and associations between EMA-measured psychosocial, contextual factors and diabetes self-management. Methods: The inclusion criteria were: research of EMA and diabetes self-management behaviors such as glucose checks, administration of insulin and eating-and dietary intake behaviors among persons with diabetes. A comprehensive search of several databases was conducted across all dates until July 2020. Results: A modified Checklist for Reporting EMA Studies was used to assess the quality of studies. Among the ten included studies, participants were predominantly White adolescents with type 1 diabetes (T1D) and type 2 diabetes was studied in two studies. Time-varying, psychosocial contexts such as negative affect or negative social interaction were associated with missed insulin injection and poor adherence to glucose check. More preceding psychological stress was associated with more calorie intake from snacks or binge eating behaviors. Mornings were the most challenging time of day for adherence to diabetes self-management among adolescents with T1D. Intentional insulin withholding was more common in the afternoon in adults with T1D. Conclusions: EMA has potential clinical utility in the assessment of diabetes self-management and in the development of timely and individualized diabetes interventions.

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Background: Little is known about the longitudinal association between social participation and incident frailty in community-dwelling older adults in general and particularly in China. This study examined the impact of type, frequency and diversity of social participation on incident physical frailty at two-year follow-up. Method: Longitudinal data from three waves of the China Health and Retirement Longitudinal Study were used. Older adults who were non-frail and aged 60 years or more at baseline and had information on physical frailty at follow-up were included. Frailty was measured using the modified frailty phenotype criteria. Social participation was measured as the type, frequency and diversity of engagement in social activities, including interacting with friends, playing group games, participating in sports clubs, community-related organizations, and voluntary activities. Results: A total of 6959 eligible respondents were included. Playing group games (OR=0.73, 95%CI=0.55–0.96) or participating in the activities of sports clubs (OR=0.54, 95%CI=0.34–0.85) once or more times per week led to a decreased risk of developing frailty in two years whereas participating in voluntary activities occasionally (OR=0.50, 95%CI=0.30–0.84) had a protective effect on the development of frailty. More diverse social participation was significantly associated with lower risk of incident frailty at two-year follow-up. Conclusions: The association between social participation and onset of physical frailty differed by the specific type and frequency of the activities that older adults engaged in. Promoting social participation of various types and at an appropriate frequency may be a promising way to mitigate the burden associated with physical frailty among older adults.

Abstract

Background: Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centered outcomes. Objective: To understand the facilitators that contributed to the success of the Primary Palliative Care for Emergency Medicine (PRIM-ER) quality improvement pilot intervention. Design: Effectiveness was evaluated through semi-structured interviews. Reach outcomes were measured by percent of all full-time emergency providers (physicians, physician assistants, nurses) who completed the intervention education components and baseline survey assessing attitudes and knowledge on end-of-life care. Participants: Emergency medicine providers affiliated with two medical centers (N = 197). Interviews conducted with six key informants at both institutions. Approach: Interviews were recorded, transcribed, and analyzed using deductive and inductive approaches. Descriptive statistics include reach outcomes and baseline survey results. Key Results: Both sites successfully implemented all components of the intervention and achieved a high level (> 75%) of intervention reach. Two themes emerged as facilitators to successful effectiveness facilitators of PRIM-ER: (1) institutional leadership support and (2) leveraging established quality improvement (QI) processes. Institutional support included leveraging leadership with authority to (a) mandate trainings; (b) substitute PRIM-ER education for normally scheduled education; and (c) provide protected time to implement intervention components. Effectiveness was also enhanced by capitalizing on existing QI processes which included (a) leveraging interdisciplinary partnerships and communication plans and (b) monitoring performance improvement data. Conclusions: Capitalizing on strong institutional leadership support and established QI processes enhanced the reach and effectiveness of the PRIM-ER pilot. These findings will guide the PRIM-ER researchers in scaling up the intervention in the remaining 33 sites, as well as enhance the planning of other complex quality improvement interventions in clinical settings. Registration Details: ClinicalTrials.gov Identifier: NCT03424109; Grant Number: AT009844-01.

Abstract

Background: Home-based exercise interventions might be a desirable long-term option for breast cancer survivors to enhance compliance and long-term health benefits. Purpose: To assess the effectiveness of a home-based intervention aimed at helping survivors of breast cancer meet the physical activity guidelines of the American College of Sports Medicine. Methods: Eighty-nine women (age: 55.4 ± 10 years; body mass index: 31 ± 6.5 kg/m2) from 2 cancer centers serving Hispanic women participated in this study. Women underwent a baseline assessment of cardiorespiratory fitness, muscle endurance and strength, flexibility, range of motion, and extremity disability. After baseline measures, women were randomized into a control or exercise group. The exercise intervention consisted of a walking program, elastic band strengthening, and flexibility exercises performed at home. The outcome measures were reassessed 16 weeks after baseline measures. Results: The intervention showed a strong effect of time on muscle strength and shoulder range of motion, and time and group for self-reported disability. There were no differences in sedentary behavior, physical fitness, and disability measures across intervention groups, including both exercise groups combined and changes over time between intervention groups. Conclusion: It appears that a home-based intervention affects only upper-body strength and related disability, indicating that other components might need closer monitoring for significant changes to occur across time.

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Objective: This study aims to evaluate the effects of a symptom management intervention (SMI) based on symptom management group sessions combined with a mobile health (mHealth) application (app) on the knowledge of symptom management, the certainty of symptom self-management, symptom severity, symptom distress, medication adherence, social support, and quality of life among persons living with HIV (PLWH) in China. Methods: A parallel randomized controlled trial with 61 PLWH was conducted in Shanghai, China. The participants in the control group (n = 30) downloaded the Symptom Management (SM) app according to their needs and preferences, and received routine follow-ups. The participants in the intervention group (n = 31) were guided to download and use the SM app, and received four tailored weekly group sessions at routine follow-ups. Each group session lasted for approximately 2 h and targeted one of the major modules of the SM app. All the outcomes were assessed at baseline and post-intervention. The study was registered with the Chinese Clinical Trial Registry (ChiCTR1900024821). Results: The symptom management knowledge and certainty of symptom self-management were significantly improved after the intervention (all P < 0.01). Compared with the control group, the scores of symptoms reasons knowledge score improved 11.47 points (95% CI: 3.41, 19.53) and scores of symptoms self-management knowledge score improved 12.80 points (95% CI: 4.55, 21.05) in the intervention group after controlling for covariates. However, other outcomes did not show statistically significant differences between the intervention group and the control group (P > 0.05). Conclusion: The SMI could improve PLWH's symptom management knowledge and certainty of symptom self-management. Multi-center studies with larger sample sizes and longer follow-ups are needed to further understand the effects of SM app on ameliorating symptom severity and symptom distress. More innovative strategies are also needed to promote and maintain the sustainability of the SM app.

Abstract

Objectives: Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes. Methods: We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician. Results: One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = −1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = −0.98, 95% confidence interval = −2.03 to −0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant. Conclusions: The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.

Abstract

Depression and anxiety, which may influence antiretroviral therapy (ART) medication adherence, are prevalent among persons living with HIV (PLWH) in China. This parallel two-arm clinical controlled trial aimed to examine the effects of a nurse-delivered cognitive behavioral intervention (CBI) on depression, anxiety, and ART medication adherence in Chinese PLWH. Using in-person and online recruitment, 140 PLWH ages 18 years and older who were undergoing ART and had a Patient Health Questionnaire-4 score of ≥2 were assigned to the 10-week-long CBI group or the routine follow-up group according to their preference. Outcomes were measured at baseline, postintervention, and 6-month follow-up. Results showed significant intervention effects on depression maintained until the 6-month follow-up. Although anxiety and ART medication adherence did not show robust effects between conditions, amelioration trends for these outcomes were also found. Our study demonstrated that the nurse-delivered CBI could help Chinese PLWH ameliorate depression.

Abstract

Objective: Both diabetes mellitus (DM) and poor oral health are common chronic conditions and risk factors of Alzheimer’s disease and related dementia among older adults. This study assessed the effects of DM and complete tooth loss (TL) on cognitive function, accounting for their interactions. Methods: Longitudinal data were obtained from the 2006, 2012, and 2018 waves of the Health and Retirement Study. This cohort study included 7,805 respondents aged 65 years or older with 18,331 person-year observations. DM and complete TL were self-reported. Cognitive function was measured by the Telephone Interview for Cognitive Status. Random-effect regressions were used to test the associations, overall and stratified by sex. Results: Compared with older adults without neither DM nor complete TL, those with both conditions (b =-1.35, 95% confidence interval [CI]:-1.68,-1.02), with complete TL alone (b =-0.67, 95% CI:-0.88,-0.45), or with DM alone (b =-0.40, 95% CI:-0.59,-0.22), had lower cognitive scores. The impact of having both conditions was significantly greater than that of having DM alone (p < .001) or complete TL alone (p = 0.001). Sex-stratified analyses showed the effects were similar in males and females, except having DM alone was not significant in males. Conclusion: The co-occurrence of DM and complete TL poses an additive risk for cognition. Healthcare and family-care providers should pay attention to the cognitive health of patients with both DM and complete TL. Continued efforts are needed to improve older adults’ access to dental care, especially for individuals with DM.