The Burden of Pneumonia- and Malnutrition-Associated Mortality Among U.S. Adults Aged 65 Years and Older, 1999–2020

1. Introduction

Among older adults, pneumonia and malnutrition frequently coexist in a mutually reinforcing and potentially fatal cycle. Age-related immunosenescence, frailty, and declining physiological reserve increase susceptibility to acute respiratory infections, while malnutrition accelerates skeletal muscle loss, promotes sarcopenia, and impairs immune function [1,3]. Once pneumonia develops, the associated inflammatory and hypermetabolic response often worsens anorexia, disrupts swallowing function, and further depletes nutritional reserves, thereby amplifying functional decline and vulnerability [2,4]. In this setting, disease-related malnutrition is not merely a secondary comorbidity, but both a marker of baseline physiologic frailty and an active contributor to poor outcomes during acute respiratory illness [5]. Despite this biologic interplay, the combined mortality burden of pneumonia and malnutrition remains insufficiently characterized at the population level, particularly among older adults who face increasing agerelated vulnerability and persistent healthcare disparities.

To address this gap, we analyzed national mortality trends among U.S. adults aged 65 years and older using the CDC WONDER Multiple Cause of Death database from 1999 through 2020. We evaluated age-adjusted mortality patterns associated with co-occurring pneumonia and malnutrition and examined disparities across sex, age group, race and ethnicity, urbanization status, census region, state, and place of death. By identifying disproportionately affected populations, this study aims to provide an epidemiologic foundation for integrating respiratory infection prevention strategies with early nutritional assessment and intervention in older adults.

2. Methods

In this study, we focused on the mortality trend and disparities of pneumonia and malnutrition in older adults aged 65 years or above, using data from the CDC WONDER website, where data were examined from 1999–2020 [6]. The study included only adults above 65 years due to the greater susceptibility to infections and nutritional deficiencies, along with longer exposure to age-related comorbidities, thereby representing the burden of these conditions in older populations.

Deaths related to pneumonia and malnutrition were identified using ICD-10 codes for pneumonia (J10.0, J11.0, J12–J18, J69) and malnutrition (E40–E46) [7]. The Multiple Cause-of-ofDeath public-use data from death certificates were studied to identify cases where both pneumonia and malnutrition were reported in the multiple cause of death (MCD) fields.

This study fell under exemption from Institutional Review Board (IRB) approval because it used a de-identified government-issued public use dataset and adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting[8].

Data Extraction

The data for age group, race, sex, state, place of death, census region, and 2013 urbanization were examined. Individuals aged 65 years and older were divided into 10-year age groups. Race and ethnicity were classified as American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, and White; Hispanic or Latino origin was analyzed separately, consistent with CDC WONDER, which codes Hispanic ethnicity independently of race.

The extracted data were from all 50 U.S. states, U.S. territories, and the District of Columbia.

Place of death included medical facilities (including outpatient, inpatient, emergency, death at arrival, or status unknown), decedent's home, hospice facility, nursing home or long-term care, and other locations.

Census regions were classified using CDC WONDER codes CENS-R1 to CENS-R4, corresponding to the Northeast, Midwest, South, and West. Levels of urbanization included Large Central Metro, Large Fringe Metro, Medium Metro, Small Metro, Micropolitan (Nonmetro), and NonCore (Nonmetro) [9].

Statistical Analysis

Crude mortality rates (CMRs) and age-adjusted mortality rates (AAMRs) were calculated to examine national temporal trends. CMRs were derived by dividing the number of pneumonia and malnutrition-related deaths by the corresponding U.S. population for each year. AAMRs were calculated by standardizing the mortality counts to the 2000 U.S. standard population [9].

Trends in both crude and age-adjusted mortality rates were assessed using the Joinpoint Regression Program (Version 4.9.0.0, National Cancer Institute), which fits log-linear regression models composed of consecutive linear segments connected by joinpoints where significant temporal changes occur [10].

Autocorrelation was checked by the Joinpoint Regression Program, and default permutation tests were used to determine the number of joinpoints [10]. This approach has been used extensively in population-level mortality analyses and identifies statistically significant turning points in long-term trends.

Annual percent change (APC) estimates with 95% confidence intervals (CIs) were generated, and trends were considered increasing or decreasing if the corresponding slope deviated markedly from zero based on two-sided t-tests. A P value of <0.05 was considered statistically significant.

3. Results

Pneumonia- and malnutrition-related mortality among adults aged ≥65 years accounted for 81,753 deaths in the United States between 1999 and 2020. Among these deaths, 41,851 (51.19%) occurred in females, while 39,902 (48.81%) occurred in males. (Supplemental Table1).

Regarding the location of death, the majority occurred in medical facilities during inpatient care, accounting for 53,210 deaths (65.08%). This was followed by nursing home or long-term care facilities, which accounted for 17,325 deaths (21.19%), and decedents homes, accounting for 7,062 deaths (8.64%). (Supplemental Table 2, Figure 1).

3.1. Overall Trend for AAMR.

Over this period, the AAMR decreased from 13.82 in 1999 to 11.90 in 2020. Trend analysis demonstrated a significant decline from 1999 to 2009 [APC: -7.27%; 95% CI: -8.28 to -6.26; P < 0.001], followed by a significant rise from 2009 to 2017 [APC: 2.17%; 95% CI: 0.17 to 4.22; P = 0.036]. Subsequently, a significant increase was observed from 2017 to 2020 [APC: 13.25%; 95% CI: 6.96 to 19.90; P < 0.001] (Supplemental Tables 3 and 4; Figure 2).

3.2. Demographic Differences

3.2.1. Sex-Stratified Analysis

Throughout the study period, males consistently had higher AAMRs than females. From 1999 to 2020, the AAMR among males decreased from 17.46 in 1999 to 15.13 in 2020. Trend analysis demonstrated a significant decrease from 1999 to 2010 [APC: -6.94%; 95% CI: -7.67 to -6.21; P < 0.001] followed by a significant increase from 2010 to 2018 [APC: 3.40%; 95% CI: 1.82 to 5.00; P < 0.001], and a sharp significant increase between 2018 and 2020 [APC: 18.16%; 95% CI: 8.11 to 29.14; P < 0.001].

From 1999 to 2020, the AAMR among females decreased from 11.69 in 1999 to 9.52 in 2020.

There was a significant decrease from 1999 to 2009 [APC: -7.46%; 95% CI: -8.44 to -6.48; P <0.001], followed by a significant increase between 2009 and 2017 [APC: 2.34%; 95% CI: 0.36 to4.36; P = 0.024], and a significant rise between 2017 and 2020 [APC: 11.64%; 95% CI: 5.04 to18.64; P = 0.002] (Supplemental Tables 3 and 4; Figure 2).

3.2.2. Race-Stratified Analysis

At baseline in 1999, the highest AAMR was observed among American Indian or Alaska Native individuals; however, by 2020, the highest AAMR was observed among Black or African American individuals, followed by American Indian or Alaska Native, White, Hispanic or Latino, and Asian or Pacific Islander individuals.

Among Asian or Pacific Islander individuals, the AAMR demonstrated a significant decline from 12.23 in 1999 to 6.21 in 2008 [APC: −5.64%; 95% CI: −8.55 to −2.63; P = 0.001], followed by a significant increase from 2008 to 2020, reaching 9.31 in 2020 [APC: 2.66%; 95% CI: 1.14 to 4.19; P = 0.002].

Among American Indian or Alaska Native individuals, the AAMR showed a significant decline from 23.78 in 1999 to 7.93 in 2014 [APC: −6.88%; 95% CI: −8.99 to −4.71; P < 0.001], followed by a statistically non-significant increase from 2014 to 2020, reaching 12.23 in 2020 [APC:6.11%; 95% CI: −1.51 to 14.31; P = 0.111].

Among Black or African American individuals, the AAMR declined significantly from 19.85 in 1999 to 9.61 in 2010 [APC: −6.68%; 95% CI: −7.67 to −5.68; P < 0.001], followed by a statistically non-significant increase from 9.61 in 2010 to 10.27 in 2018 [APC: 1.41%; 95% CI: −0.78 to 3.65; P = 0.190]. A sharp and statistically significant increase occurred between 2018 and 2020, reaching 14.66 in 2020 [APC: 19.24%; 95% CI: 4.99 to 35.42; P = 0.010].

Among White individuals, the AAMR declined significantly from 13.26 in 1999 to 6.31 in 2009 [APC: −7.40%; 95% CI: −8.42 to −6.36; P < 0.001], followed by a significant increase from 6.31 in 2009 to 7.97 in 2017 [APC: 2.39%; 95% CI: 0.27 to 4.56; P = 0.029]. A further significant increase was observed from 2017 to 2020, reaching 11.71 in 2020 [APC: 13.71%; 95% CI: 7.24 to 20.58; P < 0.001].

Among Hispanic or Latino individuals, the AAMR declined significantly from 12.69 in 1999 to 6.69 in 2007 [APC: −7.50%; 95% CI: −10.54 to −4.35; P < 0.001], followed by a statistically nonsignificant increase from 2007 to 2018, reaching 8.75 in 2018 [APC: 1.37%; 95% CI: −0.68 to 3.45; P = 0.175]. A further statistically non-significant increase was observed from 2018 to 2020, reaching 11.61 in 2020 [APC: 17.47%; 95% CI: −2.73 to 41.86; P = 0.089] (Supplemental Tables 3 and 5; Figure 3).

3.2.3. Age Group-Stratified Analysis

When stratified into 10-year age groups, the ≥85-year age group consistently exhibited the highest AAMR, followed by the 75–84 years and 65–74 years age groups.

Among individuals aged 65–74 years, the AAMR increased from 3.96 in 1999 to 4.67 in 2020.

Trend analysis demonstrated a significant decline from 3.96 in 1999 to 2.18 in 2009 [APC: −5.86%; 95% CI: −7.21 to −4.51; P < 0.001], followed by a significant increase from 2009 to 2017, reaching 2.99 in 2017 [APC: 3.05%; 95% CI: 0.68 to 5.48; P = 0.015], which accelerated significantly from 2017 to 2020, reaching 4.67 in 2020 [APC: 14.32%; 95% CI: 7.13 to 22.00; P < 0.001].

Among individuals aged 75–84 years, the AAMR decreased from 15.05 in 1999 to 12.46 in 2020. The AAMR declined significantly from 15.05 in 1999 to 7.76 in 2009 [APC: −6.49%; 95% CI: −7.10 to −5.87; P < 0.001], followed by a significant increase from 2009 to 2018 reaching 9.22 in 2018 [APC: 1.75%; 95% CI: 0.72 to 2.80; P = 0.003], and a marked significant rise from 2018 to 2020, reaching 12.46 in 2020 [APC: 17.30%; 95% CI: 8.75 to 26.53; P < 0.001].

Among individuals aged ≥85 years, the AAMR declined from 51.93 in 1999 to 40.81 in 2020.

The AAMR decreased significantly from 51.93 in 1999 to 24.00 in 2008 [APC: −8.68%; 95% CI: −10.19 to −7.15; P < 0.001], followed by a statistically non-significant decline from 2008 to 2014, reaching 21.58 in 2014 [APC: −1.13%; 95% CI: −5.65 to 3.62; P = 0.612]. However, the trend reversed with a significant increase from 2014 to 2020, reaching 40.81 in 2020 [APC: 9.44%; 95% CI: 6.44 to 12.53; P < 0.001] (Supplemental Tables 3 and 6; Figure 4).

3.3. Regional Variations

3.3.1. Stratified by Urbanization

The AAMR decreased in both metro and non-metro areas between 1999 and 2020.

In metro areas, mortality declined significantly from 12.90 in 1999 to 6.41 in 2009 [APC:−7.17%; 95% CI: −8.30 to −6.01; P < 0.001], followed by a significant increase from 2009 to 2017, reaching 8.00 in 2017 [APC: 2.71%; 95% CI: 0.49 to 4.98; P = 0.020]. A further sharp and significant increase was observed from 2017 to 2020, reaching 11.86 in 2020 [APC: 13.93%; 95% CI: 6.93 to 21.40; P < 0.001].

3.3.2. Stratified by Census Region

Across census regions, AAMR generally declined between 1999 and 2020.

In the Northeast, AAMR declined significantly from 9.33 in 1999 to 3.90 in 2010 [APC: −7.86%; 95% CI: −8.94 to −6.78; P < 0.001], followed by a statistically non-significant increase from 2010 to 2017 reaching 4.22 in 2017 [APC: 0.91%; 95% CI: −2.57 to 4.50; P = 0.590], and a significant increase from 2017 to 2020, reaching 6.72 in 2020 [APC: 17.12%; 95% CI: 7.85 to 27.73; P =0.001].

In the Midwest, AAMR declined significantly from 15.36 in 1999 to 6.22 in 2012 [APC: −6.93%; 95% CI: −7.92 to −5.94; P < 0.001], followed by a significant increase from 2012 to 2020, reaching 10.76 in 2020 [APC: 6.25%; 95% CI: 3.85 to 8.70; P < 0.001].

In the South, AAMR declined significantly from 16.59 in 1999 to 7.82 in 2009 [APC: −7.52%; 95% CI: −8.41 to −6.62; P < 0.001], followed by a significant increase from 2009 to 2018, reaching 10.36 [APC: 2.39%; 95% CI: 0.99 to 3.82; P = 0.003], and a sharper significant increase from 2018 to 2020, reaching 14.35 in 2020 [APC: 19.13%; 95% CI: 7.90 to 31.54; P =0.002].

In the West, AAMR declined significantly from 11.70 in 1999 to 6.50 in 2009 [APC: −6.00%; 95% CI: −7.43 to −4.54; P < 0.001], followed by a significant increase from 2009 to 2020, reaching 13.01 in 2020 [APC: 5.98%; 95% CI: 4.80 to 7.19; P < 0.001] (Supplemental Tables 3 and 7; Figure 5).

3.3.3. Stratified by State

Substantial state-level variation in age-adjusted mortality rates (AAMRs) for malnutrition and pneumonia was observed. Mortality ranged from a low of 3.76 (95% CI: 3.61–3.92) in New York to a high of 17.03 (95% CI: 16.69–17.38) in Texas. States within the highest 90th percentile included Texas (AAMR: 17.03, 95% CI: 16.69–17.38), Tennessee (15.12, 95% CI: 14.56–15.69), Oklahoma (15.12, 95% CI: 14.40–15.85), South Carolina (14.59, 95% CI: 13.93–15.24), and Alaska (14.57, 95% CI: 12.19–16.95), reflecting markedly elevated mortality burdens. In contrast, states within the lowest 10th percentile included New York (3.76, 95% CI: 3.61–3.92), Florida (4.80, 95% CI: 4.65–4.96), Massachusetts (5.34, 95% CI: 5.00–5.64), Connecticut (5.70,95% CI: 5.27–6.12), and the District of Columbia (5.88, 95% CI: 4.76–7.19), indicating comparatively lower mortality rates. Overall, the highest-burden state exhibited more than a fourfold higher AAMR compared with the lowest-burden state across the United States during the study period (Supplemental Table 9, Figure 7).

4. Discussions

Overall

The trend in age-adjusted mortality rates (AAMR) for pneumonia and malnutrition from 1999 to 2020 demonstrates a pronounced U-shaped trajectory, reflecting the reversal of earlier public health gains. Between 1999 and 2009, AAMR declined substantially, supported by expanded primary care [11], increased vaccination coverage [12], and sustained advances in healthcare delivery and biomedical innovation [15,16]. Post-recession economic recovery further contributed to reductions in all-cause mortality among older adults [13,14]. However, this trajectory reversed after 2009, with mortality rates increasing prior to the COVID-19 pandemic, particularly during 2017–2019. This pre-pandemic rise suggests that widening health disparities, an increasing burden of comorbidities [17], and deterioration in pneumonia-related outcomes were already eroding earlier clinical gains. In parallel, malnutrition mortality among individuals aged ≥75 years increased markedly over the period 2000–19, rising from 19.5 (95% uncertainty interval [UI]: 18.8–20.1) to 49.2 [18], reflecting a sustained and progressive vulnerability in older populations.

This worsening trajectory has been further compounded by systemic inefficiencies in healthcare delivery, particularly fragmented care pathways and suboptimal coordination of inpatient and post-acute services [20]. Although preventive coverage, including influenza vaccination, expanded substantially by 2014 [21], improvements in preventive uptake have not been matched by equivalent gains in inpatient care quality or nutritional support. Malnourished patients consistently experience prolonged hospitalization, higher healthcare expenditure, and increased in-hospital complications [19]. Similarly, hospital-acquired pneumonia remains a major driver of inpatient morbidity, with incidence rates ranging from 6 to 8.6 cases per 1000 admissions in high-income settings, and substantially higher rates observed in resource-limited health systems [22], underscoring persistent gaps in infection prevention and control.

Place of Death

Most deaths from pneumonia and malnutrition occur in medical facilities (65.08%), followed by nursing homes or long-term care settings (21.19%), while a smaller proportion occur at home (8.64%). While pneumonia is a leading cause of hospital admission in the United States, it also carries a substantial global burden, accounting for approximately 6.8 million hospitalizations and 1.1 million deaths annually among individuals over 65 years of age [23,24]. The high in-hospital mortality observed reflects the clinical severity of the illness, with a significant proportion of patients requiring intensive care; approximately 23% are admitted to the ICU [25].

Nursing homes–acquired pneumonia (NHAP) remains a major concern in older adults, particularly given the increasing population residing in long-term care facilities [26]. Advanced age, multiple comorbidities, and malnutrition serve as key factors contributing to poorer clinical outcomes in these settings. In contrast, deaths occurring at home are less frequent, likely due to limited access to intensive monitoring and advanced medical interventions outside of institutional care [27].

Overall, these patterns highlight the concentration of severe pneumonia-related mortality within healthcare institutions. This underscores the critical need for improved preventive strategies, early intervention, and targeted nutritional support for high-risk populations, particularly within hospitals and long-term care facilities [28].

Sex

While females account for a slightly higher absolute number of deaths (51.19%), males consistently exhibit higher mortality rates overall. This discrepancy is likely driven in part by differences in healthcare utilization, as women are more likely than men to engage in preventive and non-acute health services [29]. For example, men show significantly lower uptake of influenza vaccination (OR 0.71, 95% CI 0.67–0.76), reflecting broader patterns of reduced preventive care engagement [30].

Beyond behavioral factors, biological sex differences in immune function may further contribute to mortality disparities. Females generally demonstrate stronger innate and adaptive immune responses, which confer enhanced protection against bacterial, viral, and parasitic infections, particularly during reproductive years [31]. This immunological advantage may partially explain lower infection-related mortality in women across multiple settings.

In addition, sex differences in lifestyle exposures and comorbidity profiles likely amplify male vulnerability. Historically higher smoking prevalence among men, who constitute the majority of global smokers, contributes to a disproportionate burden of cardiovascular and chronic respiratory disease [32]. These comorbidities significantly increase the risk of severe outcomes from infectious diseases such as pneumonia, thereby compounding male mortality risk [33].

Conversely, female mortality remains elevated in specific contexts where structural and nutritional vulnerabilities are more pronounced. In some populations, higher rates of malnutrition among women increase susceptibility to adverse health outcomes and may offset biological advantages in immunity [34]. Collectively, these findings highlight that sex differences in mortality arise from interacting behavioral, biological, and structural determinants, underscoring the need for integrated and sex-sensitive public health interventions [35].

Age Groups

The rising mortality burden among older adults reflects the convergence of biological aging processes, functional decline, and entrenched structural inequities. At the biological level, frailty, multimorbidity, and immune senescence collectively erode physiological resilience, reducing adaptive capacity and increasing susceptibility to adverse health outcomes [36]. These vulnerabilities are frequently compounded by functional impairments, particularly those affecting nutrition; for instance, age-related tooth loss impairs mastication and contributes to reduced dietary diversity and subsequent micronutrient deficiencies [37]. Nutritional risk is further shaped by socioeconomic gradients, where lower educational attainment is associated with poorer nutritional status due to limited health literacy, reduced dietary quality, and constrained capacity to implement appropriate food practices [38]. Consequently, approximately 25% of older adults are either malnourished or at high nutritional risk, underscoring a substantial and preventable public health burden [39,40]. Addressing this requires upstream structural interventions, including income security policies, expanded community-based nutritional and social support for isolated individuals (particularly those who are widowed, single, or divorced), and strengthened lifelong health and food literacy initiatives [41].

Beyond individual determinants, systemic barriers within healthcare delivery further exacerbate risk and delay timely intervention. Older adults disproportionately face financial constraints, reduced mobility, geographic inaccessibility, and digital exclusion, all of which collectively impede access to essential healthcare services [42]. These barriers are further intensified by social isolation and caregiver dependence, increasing the likelihood of delayed treatment seeking and worsened clinical trajectories. In parallel, rising vaccine hesitancy contributes to suboptimal immunization coverage, heightening vulnerability to preventable infectious diseases within this high-risk population [43]. Mitigating these intersecting risks requires a shift away from fragmented, episodic care toward integrated, person-centered models. Comprehensive geriatric assessment, interdisciplinary coordination, and shared decision-making frameworks are therefore essential to managing multimorbidity, improving functional outcomes, and reducing avoidable mortality among older adults [44].

Race

Racial and ethnic disparities in pneumonia and malnutrition-related mortality remain stark in the United States. Although White populations account for the highest absolute number of deaths, Black individuals experience the highest age-adjusted mortality rates, reflecting persistent systemic health inequities [45]. These disparities are strongly shaped by overlapping social determinants of health, including socioeconomic status [46], insurance coverage [47], barriers to primary care [45,48], and sub-optimal vaccination uptake [49].

Conversely, Hispanic populations generally exhibit lower mortality rates—a phenomenon historically termed the “Hispanic Paradox” and attributed to robust social support networks and behavioral patterns [50]. However, this relative advantage has narrowed in recent years, underscoring how shifting structural and social conditions continue to drive unequal health outcomes.

Urbanization

Age-adjusted mortality rates (AAMR) for pneumonia and malnutrition declined in both metropolitan and non-metropolitan areas between 1999 and 2020, though the overall decrease was statistically significant only in non-metropolitan regions. Both areas experienced steady reductions from 1999 to 2009, followed by a notable resurgence in mortality after 2016–2017, a trend particularly pronounced in metropolitan regions. Paradoxically, while urban older adults report greater familial cohesion [51], major cities also face higher rates of food insecurity [52]. These geographic disparities are heavily shaped by underlying socioeconomic status, race/ethnicity, and modifiable lifestyle factors [53], underscoring the critical need for targeted public health interventions tailored to both urban and rural populations.

Census and States

From 1999 to 2020, age-adjusted mortality rates (AAMR) for pneumonia and malnutrition among adults aged 65 and older declined nationally, although clear regional disparities persisted. The Northeast and Midwest experienced statistically significant improvements, whereas the South consistently recorded the highest AAMR with only a non-significant decline, suggesting a persistent burden potentially linked to socioeconomic disadvantage and food insecurity [55]. In contrast, the West showed a non-significant overall increase in mortality [54].

At the state level, disparities were substantial, with the highest-burden states exhibiting more than fourfold higher mortality rates than the lowest-burden states. These differences likely reflect variation in socioeconomic conditions, comorbidity profiles, and healthcare infrastructure. Importantly, greater primary care physician supply is associated with lower mortality, with each additional 10 primary care physicians per 100,000 population linked to a 0.9% - 1.4% reduction in respiratory deaths [55]. This underscores the importance of strengthening primary care access to reduce geographic disparities in outcomes.

5. Limitations

This study has several limitations. It relies on death certificate data, which may underreport or inconsistently record malnutrition, particularly among older adults. The lack of detailed individual-level information, such as socioeconomic status, comorbidities, or care setting, prevents adjustment for key risk factors. Regional trends may mask important local variations, and changes in coding practices or clinical recognition over time could have influenced observed patterns. Additionally, the analysis does not distinguish between types or causes of malnutrition, making it difficult to identify specific drivers of higher mortality.

Additional limitations warrant mention. Because the study period includes 2020, the first year of the COVID-19 pandemic, the post-2017 increase, and particularly the sharp rise in 2020—is likely confounded by COVID-19, which is frequently coded with pneumonia (e.g., J12.x) and which disrupted nutritional support and continuity of care. In addition, multiple cause-of-death data cannot establish the temporal or causal direction between pneumonia and malnutrition. Finally, comparisons across states, regions, and population subgroups are ecological and may not reflect individual-level risk.

6. Conclusion

Pneumonia and malnutrition-related mortality among older adults in the United States followed a pronounced U-shaped trajectory from 1999 to 2020, with substantial declines in the early 2000s followed by a reversal after 2017, prior to the full impact of the COVID-19 pandemic that accelerated sharply in 2020, the first year of the COVID-19 pandemic. This resurgence suggests that earlier gains in prevention and clinical management were not sustained and highlights persistent vulnerabilities among older adults, particularly males, individuals aged ≥85 years, and Black/African American populations, who experienced the highest mortality burden. The concentration of deaths in hospitals and nursing facilities underscores the complex interaction between frailty, nutritional decline, and infectious disease in advanced age, as well as potential gaps in care coordination across acute and long-term care settings. These findings support the need for integrated public health strategies that combine pneumonia prevention and treatment with routine nutritional screening, long-term nutritional support, and improved continuity of care, while also addressing structural determinants such as food insecurity, inequitable healthcare access, and fragmented chronic care services to reduce preventable mortality among vulnerable older adults.