Incidence of Aspiration and Dysphagia in Geriatric Trauma Patients

Abstract

Background

Trauma is a leading cause of death worldwide. Dysphagia and aspiration are potential sequelae of traumatic brain injury (TBI), yet these conditions are not always readily apparent. Fiberoptic endoscopic evaluation of swallowing (FEES) is a bedside procedure enabling real-time diagnosis of swallowing dysfunction. The aim of this study was to assess the incidence of dysphagia and aspiration in geriatric TBI patients, identify associated risk factors, and ultimately establish specific indications for FEES as a method of formal swallowing evaluation.

Methods

A retrospective review was completed on all geriatric (65 or older) trauma patients evaluated in our level I trauma center from July 2021 to July 2023 who had a TBI defined by Abbreviated Injury Scale (AIS) head ≥3. Rates of dysphagia and aspiration were collected in addition to risk factors and associated clinical characteristics. Univariate and multivariable analyses were performed with significance defined by a P-value <0.05.

Results

In this study (n = 417), 21.8% of participants were found to have dysphagia and 6.9% aspirated. Both dysphagia and aspiration were associated with more hospital and ICU days, lower functional status at discharge (FSD), and lower likelihood of being discharged home. Glasgow Coma Scale (GCS) score less than 15 was an individual predictor of dysphagia as well as mortality.

Discussion

By identifying factors associated with dysphagia and aspiration, we can risk stratify geriatric TBI patients to receive a standardized swallowing evaluation with FEES in an effort to prevent unnecessary morbidity and mortality.

Keywords

geriatric trauma dysphagia aspiration fiberoptic endoscopic evaluation of swallowing traumatic brain injury

Key Takeaways

• Glasgow Coma Scale <15 can serve as a rapid screening tool and is associated with increased odds of dysphagia and mortality.

• Aspiration was associated with a fall mechanism of injury.

• Both dysphagia and aspiration lead to increased length of stay as well as poorer discharge outcomes.

Introduction

Our nation’s median age continues to increase.¹ It is predicted that the percentage of trauma patients aged 65 years and greater will reach approximately 40% in 25 years.² Geriatric trauma patients present a unique challenge to the traumatologist, as they often have more comorbidities, polypharmacy use, and less physiologic reserve compared to their younger counterparts. It is this interplay between impaired physiology and frailty that increases their vulnerability to morbidity and mortality.^3,4

Dysphagia is generally defined as impaired swallowing, while aspiration refers to food, liquid, or other material passing through the vocal cords into the airway, which can be a sequela of dysphagia. Swallowing is a complex physiological action, and when dysphagia occurs, increases in mortality, morbidity, and hospital resource utilization are seen.⁵ The rate of dysphagia increases with age, with a lifetime prevalence of dysphagia in geriatric patients estimated to be as high as 38%.⁶

While swallowing evaluations are often universal protocol following stroke, this is not currently the case in trauma patients. As a result, dysphagia is often recognized retrospectively because of its complications.^5,7 While screening and bedside evaluation tests are utilized clinically, such as the Massey Bedside Swallowing Screen or the Gugging Swallowing Screen, none of these have been validated for diagnosing dysphagia in older adults.⁸ When aspiration or dysphagia is suspected, a formal swallowing study should be obtained. Video fluoroscopic swallow study (VFSS), also known as the modified barium swallow study, and fiberoptic endoscopic evaluation of swallowing (FEES) are the 2 most commonly utilized modalities.⁹ Video fluoroscopic swallow study utilizes X-ray in real-time, while FEES allows for direct endoscopic visualization of the pharyngeal and laryngeal structures as swallowing occurs.⁹ There is, however, a paucity of data evaluating FEES as the diagnostic modality of choice in trauma patients. Owing to its bedside utility and lack of ionizing radiation, FEES is likely to be more helpful for this population. It may also allow for timelier implementation of nutritional support in the elderly population, as FEES can be performed by a licensed speech therapist, after obtaining informed consent, at the time of their evaluation. The goal of this study was to assess the incidence of dysphagia and aspiration in geriatric trauma patients, as well as to identify risk factors and associated characteristics of these diagnoses. Through this research, we aimed to set up specific indications for FEES as a protocolized evaluation of dysphagia and aspiration.

Methods

After approval from our institutional review board, we conducted a single-center, cross-sectional analysis of trauma patients 65 years of age and older presenting to our level I trauma center between July 1, 2021, and July 1, 2023. A total of 1289 patients were received from our trauma registry; however, after exclusions were made, a total of 417 charts were reviewed. Patients included were those with a TBI defined by an abbreviated injury scale (AIS) head ≥3. Frailty in this population was measured using the Clinical Frailty Score of 1 = Very Fit, 2 = Well, 3 = Managing Well, 4 = Vulnerable, 5 = Mildly Frail, 6 = Moderately Frail, 7 = Severely Frail, 8 = Very Severely Frail, and 9 = 9 = Terminally Ill. Patients were excluded if they had a pre-existing dysphagia diagnosis, a do-not-resuscitate (DNR) status, withdrew care, were aged less than 65 years, or had an AIS head <3. Demographics, clinical characteristics, and outcome variables were collected. We compared these variables amongst those who developed dysphagia in the hospital, as well as those who had an aspiration event during their admission.

We performed our statistical analysis using Stata/SE version 17.0. A Shapiro-Francia test was conducted to evaluate the normality of variables. All continuous variables were found to be non-normally distributed; therefore, we ran Mann-Whitney U tests for these continuous variables. These data are presented as median (IQR) vs median (IQR), P-value for no dysphagia vs dysphagia. Additional Mann-Whitney U tests were conducted to compare data for those with aspiration to those without aspiration. We ran Chi-squared tests for categorical variables to determine associations between those with dysphagia and those without dysphagia to risk factors and outcomes. Furthermore, additional Chi-squared tests were conducted to determine associations between those with aspiration and those who did not aspirate to risk factors and outcomes. Data were reported as frequency (percentage of population for no dysphagia vs dysphagia) or frequency (percentage of population for no aspiration vs aspiration), P-value. Multivariable logistic regressions were conducted to assess risk factors predictive of aspiration, dysphagia, and mortality. P-values <0.05 were considered statistically significant.

Results

A total of 417 patients met the inclusion criteria. Table 1 compares patients with and without a dysphagia diagnosis during admission. Of this population, 91 (21.8%) developed dysphagia. Neither age nor mechanism of injury (MOI) differed between the 2 groups; however, we did find several significant associations related to a dysphagia diagnosis. Patients with dysphagia had lower GCS (15 (14-15) vs 14 (13-15), P < 0.001), higher frailty scores (5 (4-6) vs 4 (3-5), P < 0.001), a speech therapy evaluation (21.47% (n = 70) vs 93.41% (n = 85), P < 0.001), increased diet order change (12.92% (n = 42) vs 78.02% (n = 71), P < 0.001), increased unplanned ICU admission (1.84% (n = 6) vs 6.59% (n = 6), P = 0.016), and increased unplanned intubation (2.45% (n = 8) vs 8.79% (n = 8), P = 0.005), with longer intubation days (0 (0-0) vs 0 (0-1), P < 0.001). Dysphagic patients also had longer ICU length of stay (LOS) (1 (1-2) vs 2 (1-5), P < 0.001) and hospital LOS (4 (2-6) vs 8 (4-15), P < 0.001). With a lower functional status at discharge (FSD) (18 (16-20) vs 14 (10-17), P < 0.001), patients with dysphagia also had a lower rate of being discharged home (52.25% (n = 151) vs 10.59% (n = 9), P < 0.001).

Table 1.

Clinical Characteristics and Outcomes of Patients With Dysphagia

	No dysphagia (n = 326)	Dysphagia (n = 91)	P-value
Age^a	79 (72-86)	82 (75-88)	0.092
Gender: Male^b	163 (50)	54 (59.34)	0.115
Race: White^b	310 (95.68)	85 (93.41)	0.245
MOI: Fall^b	284 (88.20)	76 (85.39)	0.192
GCS^a	15 (14-15)	14 (13-15)	<0.001
AIS head^a	4 (3-4)	4 (3-5)	0.823
Frailty score^a	4 (3-5)	5 (4-6)	<0.001
Speech consult^b	70 (21.47)	85 (93.41)	<0.001
Diet change^b	42 (12.92)	71 (78.02)	<0.001
Feeding strategy change^b	52 (1.95)	20 (21.98)	0.179
Unplanned ICU admission^b	6 (1.84)	6 (6.59)	0.016
Unplanned intubation^b	8 (2.45)	8 (8.79)	0.005
Ventilator days^a	0 (0-0)	0 (0-1)	<0.001
Tracheostomy days^a	4.5 (4-8)	13.5 (6-21)	0.286
FSD^a	18 (16-20)	14 (10-17)	<0.001
Discharged home^b	151 (52.25)	9 (10.59)	<0.001
ICU LOS^a	1 (1-2)	2 (1-5)	<0.001
Hospital LOS^a	4 (2-6)	8 (4-15)	<0.001
Mortality^b	38 (11.66)	6 (6.59)	0.165

^aMedian (IQR).

^bn (% of population); MOI: mechanism of injury; GCS: Glasgow Coma Score; ICU: intensive care unit; FSD: functional status at discharge; LOS: length of stay.

Twenty-nine patients had a documented aspiration event. Characteristics of those with and without aspiration are depicted in Table 2. Risk factors found to be associated with developing aspiration that reached statistical significance similarly included speech therapy evaluation (32.99% (n = 128) vs 93.10% (n = 27) P < 0.001), increased diet order change (23.77% (n = 92) vs 72.41% (n = 21), P < 0.001), increased unplanned ICU admission (2.32% (n = 9) vs 10.34% (n = 3), P = 0.013), and increased unplanned intubation (2.84% (n = 11) vs 17.24% (n = 5), P < 0.001) with longer intubation days (0 (0-0) vs 0 (0-2), P = 0.005). Patients with aspiration also had longer ICU LOS (1 (1-2) vs 3 (1-10), P < 0.001) and a longer hospital LOS (4 (2-7) vs 16 (6-22), P < 0.001). Similar to those with dysphagia, patients with aspiration had a lower FSD (18 (16-20) vs 14 (10-16), P < 0.001) and a lower rate of being discharged home (45.66% (n = 158) vs 7.14% (n = 2), P = 0.009). Additional factors associated with aspiration, but not dysphagia, included a fall MOI (87.17% (n = 333) vs 93.10% (n = 27), P = 0.036), feeding strategy alteration (15.21% (n = 59) vs 44.83% (n = 13), P < 0.001), and more tracheostomy days (4 (2-4.5) vs 10 (7-16.5), P = 0.029). Unlike those with dysphagia, there was no significant difference in frailty scores between those who aspirated (4 (4-5)) and those who did not aspirate (4 (3-5), P = 0.390).

Table 2.

Clinical Characteristics and Outcomes of Patients With Aspiration

	No aspiration (n = 388)	Aspiration (n = 29)	P-value
Age^a	80 (73-87)	82 (78-88)	0.090
Gender: Male^b	199 (51.29)	18 (62.07)	0.262
Race: White^b	368 (95.34)	27 (93.10)	0.786
MOI: Fall^b	333 (87.17)	27 (93.10)	0.036
GCS^a	15 (14-15)	15 (15-15)	0.232
AIS head^a	4 (3-4)	4 (3-5)	0.396
Frailty score^a	4 (3-5)	4 (4-5)	0.3895
Speech consult^b	128 (32.99)	27 (93.10)	<0.001
Diet change^b	92 (23.77)	21 (72.41)	<0.001
Feeding strategy change^b	59 (15.21)	13 (44.83)	<0.001
Unplanned ICU admission^b	9 (2.32)	3 (10.34)	0.013
Unplanned intubation^b	11 (2.84)	5 (17.24)	<0.001
Ventilator days^a	0 (0-0)	0 (0-2)	0.005
Tracheostomy days^a	4 (2-4.5)	10 (7-16.5)	0.029
FSD^a	18 (16-20)	14 (10-16)	<0.001
Discharged home^b	158 (45.66)	2 (7.14)	0.009
ICU LOS^a	1 (1-2)	3 (1-10)	<0.001
Hospital LOS^a	4 (2-7)	15 (6-22)	<0.001
Mortality^b	43 (11.08)	1 (3.45)	0.197

^aMedian (IQR).

^bn (% of population); MOI: mechanism of injury; GCS: Glasgow Coma Score; ICU: intensive care unit; FSD: functional status at discharge; LOS: length of stay.

On multivariable logistic regression assessing for risk of dysphagia (Table 3), a moderate GCS, scores ranging from 9 to 12, significantly increased the odds of dysphagia (AOR: 7.97 (95% CI: 2.40-26.54), P = 0.001).. Frailty scores were found to be predictive of dysphagia on multivariable regression (AOR: 1.742 (95% CI: 1.35-2.24), P < 0.001). When assessing for risk of aspiration (Table 4), having a tracheostomy significantly increased the odds of aspiration (AOR: 19.36 (95% CI: 1.06-352.37), P = 0.045). Upon assessing the risk of mortality associated with each variable (Table 5), we found significant risk with moderate GCS (AOR: 37.58 (95% CI: 2.23-633.78), P = 0.012). Receiving blood products was also associated with an increased risk of mortality (AOR: 18.57 (95% CI: 2.42-142.21), P = 0.005), as was experiencing an alteration in feeding strategy (AOR: 35.12 (95% CI: 7.41-166.64), P < 0.001). Frailty scores were not significantly predictive of aspiration (P = 0.802) or mortality (P = 0.900).

Table 3.

Multivariable Logistic Regression Assessing Risk of Dysphagia

Dysphagia
Variable	Unadjusted OR	Unadjusted P-value	Adjusted OR	95% confidence interval	Adjusted P-value
ISS
Severe	0.65	0.146	0.85	.255 - 2.834	0.792
Profound	1.167	0.581	2.262	.279 - 18.338	0.445
GCS
Moderate	6.989	<0.001	7.973	2.396 - 26.537	0.001
Severe	1.585	0.323	2.008	.419 - 9.611	0.383
Age	1.022	0.112	1.009	.969 - 1.050	0.661
Frailty score	1.691	<0.001	1.742	1.354 - 2.241	<0.001
Tracheostomy	1.199	0.826	0.304	.015 - 6.153	0.438
Transfer	1.428	0.117	1.234	.726 - 2.097	0.438
AIS head	1.034	0.823	0.701	.240 - 2.051	0.517
Ventilator days	1.086	0.023	1.061	.924 - 1.218	0.402
Unplanned intubation	3.831	0.009	1.648	.199 - 13.629	0.643
					AUROC: 0.770

Abbreviations: ISS: Injury Severity Score; GCS: Glasgow Coma Score; AIS: Abbreviated Injury Severity; CVA: cerebral vascular accident.

Table 4.

Multivariable Logistic Regression Assessing Risk of Aspiration

Aspiration
Variable	Unadjusted OR	Unadjusted P-value	Adjusted OR	95% confidence interval	Adjusted P-value
ISS
Severe	1.272	0.621	2.516	.481 - 13.161	0.275
Profound	1.869	0.18	5.707	.419 - 77.782	0.191
GCS
Moderate	0.708	0.742	1.143	.133 - 9.836	0.903
Severe	1.109	0.893	2.028	.280 - 15.589	0.473
Age	1.038	0.104	1.041	.973 - 1.113	0.244
Frailty score	1.12	0.462	1.048	.727 - 1.511	0.802
Tracheostomy	15.36	<0.001	19.364	1.064 - 352.370	0.045
AIS head	1.221	0.396	0.531	.139 - 2.031	0.355
Obesity	0.793	0.625	0.735	.198 - 2.721	0.644
Ventilator days	1.113	0.011	0.966	.800 - 1.166	0.718
Unplanned intubation	7.14	0.001	1.899	.727 - 1.511	0.62
					AUROC: 0.707

Abbreviations: ISS: Injury Severity Score; GCS: Glasgow Coma Score; AIS: Abbreviated Injury Severity; CVA: cerebral vascular accident.

Table 5.

Multivariable Logistic Regression Assessing Risk of Mortality

Mortality
	Unadjusted OR	Unadjusted P-value	Adjusted OR	95% confidence interval	Adjusted P-value
Age	0.991	0.624	0.987	.897 - 1.086	0.785
GCS
Moderate	6.462	0.001	37.577	2.228 - 633.775	0.012
Severe	21.000	<0.001	1.118	.149 - 8.404	0.913
ISS
Severe	2.057	0.148	1.163	.134 - 10.086	0.891
Profound	6.719	<0.001	1.804	.241 - 13.491	0.565
Transfer	0.995	0.984	0.423	.155 - 1.154	0.093
Received blood products	5.418	<0.001	18.568	2.424 - 142.206	0.005
Barium swallow test	0.432	0.26	16.543	.673 - 406.922	0.086
Diet change	0.241	0.008	0.092	.005 - 1.841	0.119
Change in feeding strategy	16.888	<0.001	35.121	7.407 - 166.636	<0.001
Aspiration	0.287	0.225	0.177	.009 - 3.501	0.256
Dysphagia	0.535	0.17	0.056	.002 - 1.904	0.109
Frailty score	0.967	0.825	0.968	.585 - 1.604	0.900
					AUROC: 0.943

Abbreviations: ISS: Injury Severity Score; GCS: Glasgow Coma Score; AIS: Abbreviated Injury Severity; CVA: cerebral vascular accident.

Discussion

Of all the associated risk factors in our study, a depressed GCS was found to have one of the strongest associations with dysphagia, as well as increased odds of mortality. This is different than the Moller et al pilot study examining 20 traumatically injured participants which failed to demonstrate an association between GCS and dysphagia. Rather, they found a high incidence of silent aspiration in their population.¹⁰ It is important to note that dysphagia in this population is likely a complex interplay between preexisting conditions and degree of injury burden. Studies in “healthy” elderly participants have shown significant baseline incidence of silent aspiration.¹¹ The impact is likely synergistic when patients suffer a TBI or accumulate injuries. This underscores the importance of a diagnostic modality such as FEES in the geriatric trauma patient. In fact, a study evaluating risk factors for dysphagia in patients following traumatic injury to the cervical spinal cord found that increasing age and the presence of a tracheostomy resulted in greater odds of developing dysphagia.¹² It is not surprising that tracheostomy may increase dysphagia as the procedure itself disrupts the normal mechanics of swallowing by reducing sensory input, impairing laryngeal elevation, and decreasing subglottic air pressure. While our data did not show an association between tracheostomy and dysphagia, tracheostomy presence was a strong independent predictor of aspiration.

A study examining dysphagia in elderly Indonesians found increased age to be a risk factor for dysphagia which is contrary to our findings. However, like our study, they found no association between gender and increased risk of dysphagia.¹³

Other studies found similar associations. For instance, in a study examining risk of aspiration in trauma patients with a tracheostomy, each added day of mechanical ventilation resulted in 11% increased odds of aspiration.¹⁴ Interestingly, this study also elucidated a stepwise increase in risk of aspiration for every 1 unit decrease in GCS score. However, our study found that while decreased GCS was associated with both dysphagia and mortality, it was not directly linked to increased aspiration risk. This suggests dysphagia and aspiration might not always occur concurrently.

The demographic profile of patients with aspiration in our study included those with a GCS of 15, age >78, and more often experienced a fall as a mechanism for trauma admission. While not all of these variables achieved statistical significance, it is of interest to note in the context of our aim that if we are to achieve a protocol that establishes specific indications for FEES that we may miss a significant portion of aspiration in elderly trauma victims if we focused only on factors such as age, GCS, or significant associations as demonstrated in Table 2 (unplanned intubation, days intubated, unplanned ICU admission, ICU LOS, tracheostomy days, HLOS, and decreased FSD). This may also lead to a more complex scoring system with little clinically relevant application.

The answer to elucidate the intricacies of creating a useful screening protocol may in fact be more simplistic. Yang et al in a meta-analysis of over 1 million participants demonstrated an association between frailty and falls.¹⁵ Similarly, Joseph and colleagues established frailty syndrome as a major predictor of outcome increasing the odds for trauma readmission, repeated falls, and death.¹⁶ In our study, just a 1 point increase in frailty score, from 4 to 5, resulted in statistically significant increased odds of dysphagia. Accordingly, it may be more prudent to utilize frailty scoring on admission as a sole indicator for FEES evaluation rather than GCS or other variables in a more complex algorithm. Another meta-analysis in 2022 demonstrated a strong association between dysphagia and frailty (OR 3.24 vs non frail older adults).¹⁷ Additionally, Bahat et al reported a similar link between dysphagia and frailty and this association was significant regardless of age, comorbidities, or polypharmacy.¹⁸

Other studies found associations between comorbid conditions and aspiration, specifically death attributable to aspiration pneumonia. In fact, gastroesophageal reflux disease was found to be associated with 4.5 odds of death related to aspiration pneumonia, with additional associations found between anti-depressant and anti-psychotic medications as well.¹⁹

Our study’s limitations include the retrospective nature which limits insight into causation, and its single center focus may not be generalized to all settings. Future prospective studies could explore the causal links and include frailty more directly.

In conclusion, recognizing specific risk factors for dysphagia and aspiration allows the clinician to target specific interventions. We advocate for using FEES in the geriatric trauma victim with TBI, especially those with GCS <15, frailty score ≥5, tracheostomy, dietary changes, unplanned intubation, and ICU admission. While more research is called for to determine causation, our study expands upon the recognition of risk factors associated with dysphagia and aspiration. By identifying at-risk populations, we can make recommendations for a more standardized approach to swallowing evaluations. Through the implementation of such, we will be proactively preventing undesirable outcomes and offering higher-quality care.

Footnotes

Author Notes

This study will be presented as a podium presentation at the 2025 Southeastern Surgical Congress Annual Meeting on February 17th, 2025.

ORCID iDs

Julie M. Reichert

Lindsey L. Perea

Author’s Contribution

BRA was involved with data collection and writing. JMR was involved with data collection, statistical analysis, and writing. XAS was involved with data collection. ILF and SKL were involved with statistical analysis. LLP and EHB were involved with generating the study idea, data collection, statistical analysis, and writing.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Lindsey Perea-Haemonetics—research study material—not relevant to this study.

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