Background and Aims: Laparoscopic Heller's myotomy (LHM), per oral endoscopic myotomy, and pneumatic dilatation are well-established methods to treat achalasia. The ideal treatment algorithm in elderly patients is, however, still elusive. This multicenter study aims to evaluate outcomes and changes in routine therapeutic options in patients >80 years of age. Methods: Worldwide high-volume centers for the treatment of achalasia were surveyed. Therapeutic options and outcomes in patients >80 years of age were reviewed. Results: Eighty-five (54% men, mean age 84 ± 4 years) patients were studied. Primary treatment was endoscopic in 43 (51%) patients, surgical in 39 (46%) patients (30 LHM, 9 cardioplasty + gastrectomy), and medical in 3 (4%) patients. Four centers tailored treatment based on age (14% of the patients). Secondary treatment was necessary in 34 (40%) patients: 30 of them with endoscopic treatment as primary treatment. LHM was performed in 20 patients and endoscopic treatment in 14 patients. A total of 11 (13%) patients had complications after LHM. Seven had LHM or cardioplasty + gastrectomy as primary treatment. Four had LHM as secondary treatment. The mean time of hospitalization was 4 ± 2 days for those who did not have complications, and 7 ± 6 days for those who had complications. Conclusions: Most specialized centers do not tailor treatment based on advanced age. Treatment of the oldest-old patients should be based solely on their physiologic and mental health, not their age. Endoscopic treatment has a high rate of recurrence and gastrectomy a high rate of complications in his population. LHM seems to be a safe option with good outcomes in this population.