Peroral endoscopic myotomy (POEM) has been proven to be effective for the treatment of achalasia. There are limited data on efficacy and safety of POEM in elderly patients. We therefore aimed to assess the role of POEM in patients aged ≥65 years. We retrospectively analyzed POEM outcomes in young (≥18≤40 years) and elderly (≥65 years) patients, who were treated between May 2011 and April 2017. Demographic data, clinical data and treatment outcomes were compared between the two groups. During the study period, 204 patients (116 Young Group [YG], 56% male, mean age 31 ± 6.4, and 88 Elderly Group [EG] 44.3% male, mean age 72.2 ± 4.7) were enrolled. Pediatric patients (n=26) and patients aged between 41 and 64 years (n=232) were excluded. There were no differences with regard to gender or ethnicity between the two groups. High resolution manometry (HRM) was performed in 101 patients in the YG and 81 in the EG, without significant differences about the prevalence of type I and type II achalasia in the two groups. A higher prevalence of spastic motility disorders (type III achalasia, Jackhammer esophagus and Distal Esophageal Spasm –DES) was observed in the EG (25.9% vs 8.9 in EG and YG, respectively. p=0.0041). Duration of symptoms before the procedure was similar. Patients in the YG had more severe symptoms compared to EG (mean Eckardt score 8 ± 2.0 vs 7.4 ± 2.0 p=0.0350), with special regard to dysphagia (3 ± 0.2 vs 2.8 ± 0.5 p=0.0001) and chest pain (1.3 ± 1 vs 0.9 ± 0.8 p=0.0024). Mean duration of the procedure was similar in the two groups, although myotomy was longer in EG (12±3 cm vs 13±3 cm p=0.0211). This data could be explained by the higher prevalence of spastic disorders in EG. No significant differences in the rate of adverse events were found. At 6-month and at mean follow-up (24 months for both groups), clinical success (Eckardt score ≤3) was achieved in 96.4% and 96.4% of patients in YG and 96.5% and 95.4% in EG, respectively (p=n.s.). No significant differences in the two groups were observed with regard to post-POEM 4sIRP, Gastro-Esophageal Reflux and Esophagitis-rate. As well as in younger patients, POEM is a very safe and effective procedure for the treatment of major esophageal motility disorders, also in elderly patients. POEM might be recommended as the first line therapy to elderly achalasia patients.