The research, published in Frontiers in Physiology, was conducted by a multidisciplinary team spanning the departments of physiology, geriatric medicine, internal medicine, and medical gastroenterology at the gastrointestinal motility laboratory of a tertiary care center in western India. Led by Deepanjan Dey and colleagues, the study enrolled 176 consecutive patients aged over 65 years who presented with esophageal dysphagia. The investigators deliberately excluded patients with structural lesions, mixed oropharyngeal dysphagia, recent proton pump inhibitor use, systemic sclerosis, and those with severe functional dependence as measured by the Katz Activities of Daily Living index. This careful selection process was designed to isolate esophageal motility as the primary variable of interest, free from confounding by reflux-related motility changes or severe functional impairment.

Each patient underwent high-resolution manometry, the current gold standard for assessing esophageal motor function. The technique involves passing a catheter equipped with 16 channels through the esophagus to measure pressure at multiple points simultaneously, generating detailed esophageal pressure topography maps. Patients fasted for at least eight hours before the procedure, which was performed in the morning by the same gastrointestinal physiologist using a water-perfused manometry system. Standardized 5-milliliter water swallows were administered in the supine and upright positions, and the resulting swallows were classified according to the Chicago Classification version 4.0, the internationally recognized diagnostic framework for esophageal motility disorders.

The findings were striking. Normal high-resolution manometry findings were present in 57 of the 176 patients, representing 32.4 percent of the cohort. This means that nearly one-third of symptomatic older adults complaining of difficulty swallowing had entirely normal contraction metrics when objectively tested. Among those with definable esophageal motility disorders, achalasia was the most common finding, affecting 44 patients or 25 percent of the cohort, followed closely by absent contractility in 36 patients or 20.5 percent. Fragmented peristalsis accounted for 15.9 percent, while ineffective esophageal motility was the rarest disorder, affecting only 4.55 percent of elderly patients. Notably, no patient in the study showed evidence of distal esophageal spasm or jackhammer esophagus, the hypercontractile disorders that are sometimes seen in younger populations.

Within the achalasia subgroup, type II achalasia predominated, accounting for 31 of the 44 cases, or 70.45 percent of all achalasia diagnoses. Type I achalasia was found in 9 patients and type III in 4 patients. This distribution is particularly interesting when compared to a study conducted in the same demographic area but in adults aged 18 to 60 years, where type II achalasia represented only 43.9 percent of cases and type III represented 24.4 percent. In the geriatric cohort, type II achalasia was almost three times more common and type III was nearly two and a half times less frequent than in the younger population from the same region of western India. This suggests that the subtype distribution of achalasia shifts with age, an observation that could have important implications for treatment selection, since different achalasia subtypes respond differently to pneumatic dilatation and surgical myotomy.

The manometric metrics themselves revealed meaningful differences between patients with normal findings and those with motility disorders. Median basal lower esophageal sphincter pressure was 15.3 millimeters of mercury in the normal group compared with 20.5 millimeters of mercury in the disorder group. Integrated relaxation pressure, a key metric reflecting how well the esophagogastric junction relaxes during swallowing, was 6.0 millimeters of mercury in the normal group versus 11.0 millimeters of mercury in those with disorders. Distal contractile integral, which quantifies contraction vigor, was also lower in the disorder group. These values suggest that patients with normal manometry findings had adequate esophagogastric junction relaxation during normal swallows, and that the lower esophageal sphincter pressures in this geriatric cohort were lower than those typically reported in younger healthy adults.

On multivariable logistic regression analysis, two independent predictors of esophageal motility disorders emerged. Male sex carried an odds ratio of 1.92, meaning men were nearly twice as likely as women to have a definable motility disorder. The younger geriatric age band of 66 to 70 years carried an odds ratio of 2.07 compared with patients over 75 years, meaning the youngest geriatric patients were also more likely to have abnormal findings. By contrast, Katz Activities of Daily Living scores and symptom duration were not significantly associated with abnormal manometry. Correlations between chronological age and continuous manometric metrics were uniformly weak, with Pearson correlation coefficients all falling below 0.3. This finding is particularly important because it suggests that ageing per se does not produce statistically significant changes in the measured manometric parameters, undermining the notion that dysphagia in the elderly is simply a manometric expression of normal ageing.

The distribution of normal versus abnormal findings across the three geriatric age subgroups was unexpectedly non-linear. Among patients aged 66 to 70 years, 38.33 percent had normal manometry findings. This proportion increased to 66.67 percent in the 71 to 75 years group, then declined to 46.15 percent in those over 75 years. The pattern is therefore heterogeneous rather than steadily increasing with age, suggesting that factors beyond chronological age, such as symptom perception, referral patterns, or underlying pathophysiology, may vary across geriatric bands. An interesting gender observation was that normal manometry findings were twice as common among elderly women as among elderly men, despite nearly equal gender-wise referrals. The authors suggest that esophageal hypervigilance, a phenomenon wherein individuals pay excessive attention to esophageal sensations, might partially explain this disparity, although the data could not establish causality.

The study has important implications for clinical practice. Because available manometry systems measure only the contraction characteristics of the esophagus, they capture only part of the entire deglutition process. The esophageal body does not have a resting tone, so relaxation or distension-related mechanisms cannot be assessed by conventional manometry. This means that some patients with dysphagia and normal contraction metrics may have distension-related issues that explain their symptoms. The authors recommend prospective multimodal studies using techniques such as functional luminal imaging probe and impedance manometry to evaluate noncontractile mechanisms and refine referral algorithms. They also acknowledge limitations including single-center data, the use of water-perfused rather than solid-state catheters, and the absence of measures assessing frailty, sarcopenia, muscle strength, or nutritional status, which may be more closely associated with swallowing dysfunction than chronological age.

Ultimately, this relatively large geriatric manometry series provides novel regional data with a clear clinical message. Dysphagia in older patients should not be reflexively attributed to ageing. Early, structured evaluation with high-resolution manometry can identify treatable disorders such as achalasia and absent contractility, which accounted for most pathologic findings in this cohort. For primary care clinicians and gastroenterologists deciding whether to pursue manometry, complementary physiologic testing, or empiric management, the study provides actionable evidence that objective functional testing should be pursued rather than assuming that swallowing difficulty in the elderly is an inevitable consequence of growing older. The findings emphasize that appropriate referral can identify treatable conditions, improving outcomes for a vulnerable population at risk of serious complications from undiagnosed esophageal motility disorders.

Subject of Research: High-resolution manometry in the elderly: patterns of functional dysphagia, achalasia subtypes, and clinical predictors

Article Title: High-resolution manometry in the elderly: patterns of functional dysphagia, achalasia subtypes, and clinical predictors

Article References: Dey, D., Manral, R., Manrai, M., Jayapalan, A., Behal, P., & Singh, S. K. (2026). High-resolution manometry in the elderly: patterns of functional dysphagia, achalasia subtypes, and clinical predictors. Frontiers in Physiology, 17, Article 1961993. https://doi.org/10.3389/fphys.2026.1961993

Image Credits: AI Generated

DOI: 10.3389/fphys.2026.1961993

Keywords: dysphagia, high-resolution manometry, achalasia, esophageal motility, geriatric medicine, Chicago Classification, High-resolution, manometry, elderly, patterns, functional, subtypes