Trends and Racial-Geographic Disparities in Stroke-Related Mortality Among U.S. Older Adults with Diabetes Mellitus, 1999–2020

Background The combination of stroke and diabetes significantly increases mortality in older adults. Despite past progress, U.S. death rates are stalling and demographic gaps persist, yet long-term national research on this specific group remains scarce. Methods We conducted a population-based mortality study using the CDC WONDER Multiple Causes of Death database from 1999 to 2020. Adults aged ≥ 65 years with stroke as the underlying cause of death (ICD-10 codes I60–I64, I69) and DM as a contributing cause (ICD-10 codes E10–E14) were included. Crude and age-adjusted mortality rates (AAMRs) per 100,000 population were calculated using the 2000 U.S. standard population. Temporal trends were analyzed using Joinpoint regression to estimate annual percent change (APC) and average annual percent change (AAPC). Stratified analyses were performed by age, sex, race/ethnicity, urban–rural status, and region. Results A total of 201,269 deaths met inclusion criteria. Overall AAMRs declined from 32.50 in 1999 to 19.27 in 2020 (AAPC: −2.77; p < 0.001), with significant reductions until 2014 followed by stabilization. Mortality rates were higher among males and highest among non-Hispanic Black individuals. Adults aged ≥ 85 years had the greatest mortality burden. Rural areas consistently showed higher mortality than urban areas, with notable regional variation. Conclusions Stroke-related mortality among U.S. adults aged ≥ 65 years with DM declined substantially from 1999 to 2020. However, recent trend stabilization and persistent disparities highlight the need for targeted prevention strategies and equitable access to care to sustain progress in this high-risk population.