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Fiberoptic endoscopic evaluation of swallowing (FEES) can identify specific swallowing abnormalities; however, apart from aspiration, the relationship of these abnormalities to pneumonia risk is not well understood. This study aimed to identify FEES-based swallowing abnormalities associated with long-term pneumonia risk beyond airway invasion alone and to develop and internally evaluate a transparent multifeature risk score.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this retrospective cohort study, 98 geriatric patients underwent FEES. Nine predefined FEES-derived swallowing features were analyzed using a clustering approach to identify a multifeature constellation associated with pneumonia. In addition, three methods were tested to develop a scoring system: clustering-based feature selection, penalized logistic regression, and a weighted ensemble of decision tree stumps, all assessed using fivefold cross-validation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The clustering approach revealed a swallowing pattern comprising prolonged oral phase (excluding bread), delayed swallow reflex, reduced whiteout intensity, repetitive swallowing (excluding bread), piriform sinus residue, and airway invasion at PAS\u2009\u2265\u20093. A simple scoring system assigning one point per feature yielded an area under the receiver operating characteristic curve of 0.73 (95% CI 0.61\u20130.82). Each additional deficit increased pneumonia risk (odds ratio 1.82, 95% CI 1.24\u20132.67). The optimal Youden-optimized cut-off was \u2265\u20094 deficits, yielding a sensitivity of 0.46 (95% CI 0.29\u20130.63) and specificity of 0.89 (95% CI 0.79\u20130.96).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions and Implications<\/jats:title>\n                    <jats:p>Pneumonia risk in hospitalized geriatric patients with oropharyngeal dysphagia arises from the accumulation of functional swallowing impairments rather than isolated endoscopic findings. A transparent, exclusively FEES-based multifeature score provides a pragmatic framework for risk stratification.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12877-026-07803-1","type":"journal-article","created":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T07:55:35Z","timestamp":1781596535000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Multifeature endoscopic swallowing patterns associated with pneumonia in hospitalized geriatric patients: a four-year longitudinal cohort study"],"prefix":"10.1186","volume":"26","author":[{"given":"Thomas D.","family":"Kocar","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Peranovic","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bendix","family":"Labeit","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sriramya","family":"Lapa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Muhle","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sonja","family":"Suntrup-Krueger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tineke","family":"Greiner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"Minor","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rainer","family":"Dziewas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kiril","family":"Stoev","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina Rosa","family":"Neuendorff","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rainer","family":"Wirth","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maryam","family":"Pourhassan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gero","family":"Lueg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,16]]},"reference":[{"key":"7803_CR1","doi-asserted-by":"publisher","first-page":"1403","DOI":"10.2147\/CIA.S107750","volume":"11","author":"LW Baijens","year":"2016","unstructured":"Baijens LW, Clav\u00e9 P, Cras P, Ekberg O, Forster A, Kolb GF, et al. 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The study was conducted in accordance with the Declaration of Helsinki and with local institutional requirements. Owing to the retrospective study design and data collection, the requirement for written informed consent was waived by the ethics committee.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable. The manuscript does not contain any individual person\u2019s data in any form.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Thomas D. Kocar is a member of the editorial board of BMC Geriatrics. All other authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"845"}}