Stroke remains a major cause of death in older adults, and pneumonia is a frequent complication that increases mortality risk. Although overall stroke deaths have declined, long-term national trends in stroke-related mortality with pneumonia are not well defined.

We analyzed U.S mortality data (1999-2023) for adults >65years with stroke and pneumonia using CDC WONDER database and ICD codes: I60-I64, J12-J18.  Age-adjusted mortality rates (AAMRs) per 100,000 were calculated with the 2000 U.S. standard population. Trends were examined using Joinpoint regression and average annual percent change (AAPC) with 95% confidence intervals were calculated, stratified by sex, race/ethnicity, state, census region, and urban-rural status. A p-value of <0.05 was considered as significant.

Between 1999 and 2023, 261,352 stroke-related deaths with pneumonia were documented among older U.S. adults, with 51.2% in females and 48.8% in males. Most deaths occurred in medical facilities (58.5%) and nursing homes (30.7%). The overall age-adjusted mortality rate (AAMR) declined from 59.8 in 1999 to 11.7 in 2023, with steep reductions from 1999-2003 (AAPC: -6.56). Men consistently had higher AAMRs than women (31.9 vs. 21.7). By race, NH Black adults had the highest overall AAMR (36.0), followed by NH Asians (26.5), NH American Indian (25.6), NH Whites (24.8), and Hispanics (23.3). Regionally, the West (28.9) and South (26.2) carried the greatest burden. Each census region demonstrated sharp long-term declines, interrupted by 2020-2021 increases, and subsequent decreases by 2023 and rural areas with higher AAMR than urban areas (30.76 vs 24.6).

Stroke deaths with pneumonia declines markedly, but disparities by sex, race, region and rurality remain. The year 2020-2021 rise underscores the need for ongoing prevention and equitable post stroke care.