Only about one in four older adults hospitalized with pneumonia receives any evaluation for dysphagia, according to a large, national cohort study from the University of Wisconsin School of Medicine and Public Health that highlights a gap in hospital care for swallowing dysfunction known to raise the risk of pneumonia.
Researchers analyzed nearly 196,000 hospital admissions between April 2022 and December 2023, drawing on de-identified data from 943 U.S. hospitals contributing to the Premier Healthcare Database. The analysis found that swallowing evaluations are not routinely provided as part of pneumonia care for older adults, even among patients at highest risk for aspiration and recurrent infection.
“Our findings suggest a missed opportunity in pneumonia care,” said senior author Dr. Michael Pulia, an associate professor of emergency medicine and director of the Emergency Care for Infectious Diseases research program. The study, published Sept. 27 in the Journal of the American Geriatrics Society, is the first to examine swallowing-related pneumonia care at this scale.
“Pneumonia is common and highly treatable in older adults. While care is often focused rightly on antibiotics and respiratory support, swallowing dysfunction (dysphagia) is a modifiable risk factor hiding in plain sight,” he said.
The study was co-led by Dr. Nicole Rogus-Pulia, an associate professor in the Division of Geriatrics and Gerontology, UW Department of Medicine, and director of the Swallowing and Salivary Bioscience Lab. Rogus-Pulia is a leading expert on dysphagia care in older adults, including those with Alzheimer’s disease and related dementias.
Pneumonia is a serious health concern that increases in prevalence after age 60. It accounts for 1.5 million hospital admissions each year in the United States and is the leading cause of death for people with neurodegenerative diseases such as Parkinson’s disease and dementia.
There are different types of pneumonia — community-acquired pneumonia and aspiration pneumonia — but they can be difficult to tell apart. They have similar symptoms, and current diagnostic tests like chest imaging cannot easily distinguish between them.
Swallowing problems (dysphagia) can directly cause aspiration pneumonia when food or liquid enters the lungs and triggers infection. Dysphagia may also worsen any type of pneumonia by increasing the risk of aspiration during recovery. This can lead to dehydration, malnutrition or reinfection — prolonging illness and contributing to poorer health outcomes. Early evaluation helps reduce complications, shorten hospital stays and support a safe return to eating.
Speech-language pathologists (SLPs) play a central role in this care. When a pneumonia patient is referred to dysphagia services, they can provide:
- Bedside swallowing evaluations to quickly check for signs of dysphagia.
- Instrumental exams, such as a moving X-ray or a small camera inserted through the nose to see if food or liquids are entering the airway.
- Therapy to strengthen swallowing and reduce future risk of a swallowing issue that could lead to reinfection.
The study shows these services are not routinely utilized. Researchers found that among nearly 196,000 older adults hospitalized with pneumonia, only 23.6% received a bedside swallowing evaluation, 6.8% received an instrumental exam, and 11.2% received therapy. Even among high-risk groups — patients with aspiration pneumonia or neurodegenerative disease — most received no dysphagia services at all.
The strongest predictor of receiving care was having an aspiration pneumonia diagnosis, suggesting that clinician recognition of swallowing dysfunction plays a key role in determining if patients are referred to speech-language pathologists for dysphagia services. The study also found lower referral rates in rural and community hospitals, highlighting gaps in access to specialized swallowing care.
Because the study used hospital billing and documentation data, it may undercount informal clinical bedside screening for dysphagia or non-billed interventions. Also, it cannot determine whether a patient declined services or whether clinical teams documented dysphagia concerns outside of coded encounters.
“These findings show where the system breaks down,” Rogus-Pulia said. “Dysphagia is prevalent and can be addressed, but it is often overlooked. If we identify it early, we can help patients recover and avoid more serious or recurrent infections.”
The researchers say the findings point to a clear opportunity to improve pneumonia care. Better screening tools, more consistent referral pathways and greater awareness of dysphagia risk, especially among patients with neurologic conditions, could help ensure timely swallowing evaluation and treatment.
“Improving screening and referral for dysphagia among older adult patients admitted with pneumonia could meaningfully reduce complications and recurrent hospitalizations,” Pulia said. “It could make care safer for the millions of older adults impacted by pneumonia each year.”
Authors: Jordanna S. Sevitz, PhD, CCC-SLP; Meggie Griffin, MS; Nicole Rogus-Pulia, PhD, CCC-SLP; and Michael Pulia, MD, PhD.
Funding: Pulia is supported by RO1 HS028669 from the Agency for Healthcare Research and Quality, and Rogus-Pulia is supported by 1K76AG068590 from the National Institute on Aging.