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Disordered oesophageal motor function may present with symptoms of difficulty swallowing (dysphagia) or chest pain. In both nursing homes (50–60%) and general medical wards (10–30%), there is a high prevalence of dysphagia when patients are specifically questioned,²⁹ although less than half of elderly subjects who reported dysphagia in a population‐based survey had consulted a physician about it. Potential consequences of dysphagia include aspiration, which contributes substantially to mortality, and inadequate intake of nutrition.

Swallowing disorders can be classified into those of oropharyngeal (difficulty initiating a swallow) or oesophageal (impaired transport of swallowed material) origin, and these can usually be discriminated with a careful history and examination. The oropharyngeal component of swallowing comprises preparatory (chewing food, mixing with saliva, and bolus formation), oral (propulsion of the bolus by the tongue and palate to the pharynx), and pharyngeal (transport through the UOS while protecting the airway) phases. A comprehensive discussion of dysphagia of oropharyngeal origin is included in Chapter 49.

Potential causes of oesophageal dysphagia are listed in Table 17.1 Key points in the history include whether dysphagia is for solids or liquids, whether it is intermittent or progressive, and whether there are associated reflux symptoms such as heartburn.³⁰ Progressive difficulty in swallowing solids is suggestive of a structural lesion, while dysphagia for both liquids and solids is associated with motility disorders. Endoscopy provides a means to visualise and biopsy structural lesions and may also be therapeutic (for example, dilatation of a peptic stricture). Endoscopy and biopsy are also likely to be helpful when odynophagia (painful swallowing) is the presenting complaint, and in the patient with dysphagia can help exclude eosinophilic esophagitis, which is increasingly being recognised even in older patients.³¹ Barium videofluoroscopy provides complementary information regarding motor function as well as structural lesions, while manometry is of greatest use in confirming or excluding a diagnosis of achalasia.

Table 17.1 Oesophageal causes of dysphagia.

Structural lesions

Neoplasm

Peptic stricture

Rings and webs

Vascular compression

Pill esophagitis

Reflux esophagitis

Eosinophilic esophagitis

Diverticula

Motility disorders

Achalasia

Distal oesophageal spasm and jackhammer oesophagus

Non‐specific motility disorders

Systemic disease (diabetes mellitus, progressive systemic sclerosis, Parkinson’s disease)

Of the primary oesophageal motility disorders, the proportions of patients in different categories are similar in older (>60 years) and younger patients; but in older patients presenting with dysphagia, achalasia and distal oesophageal spasm are more commonly diagnosed in the older group.²⁰ While the peak incidence of achalasia is in early to mid‐adulthood, a second, smaller peak occurs in the elderly.³² Oesophageal spasm is more commonly diagnosed over 50 years of age, while non‐specific motility disorders are particularly associated with an older population.