Falls are one of the most dangerous events an older adult can experience. A single fall can lead to fractures, loss of independence, prolonged hospitalization, and even increased mortality. What many families don’t realize is that antipsychotic medications—often prescribed for agitation, restlessness, aggression, sleep problems or behavioural symptoms in dementia—significantly increase the risk of falls.

As antipsychotic prescriptions continue to rise among older adults, especially those living at home or in assisted-care environments, it’s vital for caregivers to understand why these medicines cause falls, which ones are riskier, and how to use them safely if they are truly necessary.

This article breaks down the science in simple language and brings clarity to an issue many families face.

Why Antipsychotics Increase Fall Risk

All antipsychotics—regardless of whether they are old (typical) or new (atypical)—can destabilize an older adult’s mobility and balance through multiple pathways.

1. Sedation

Many antipsychotics cause drowsiness or “heaviness” in the head.
This slows reaction time and makes falls far more likely, especially at night.

2. Drop in Blood Pressure

Drugs like quetiapine, olanzapine and chlorpromazine can cause orthostatic hypotension—a sudden fall in blood pressure when standing up.
This leads to:

• dizziness

• blackouts

• sudden collapse

3. Stiffness, Shuffling and Tremors

Older antipsychotics (and risperidone at higher doses) can cause Parkinson-like symptoms, including:

• rigidity

• shuffling gait

• poor balance

These changes often appear subtle at first, but dramatically increase fall risk.

4. Confusion and Delirium

Some antipsychotics have anticholinergic effects, which worsen memory and confusion.
When an older adult is disoriented, falls become more frequent.

5. Heart Rhythm Changes

QT prolongation and arrhythmias can lead to fainting spells.

Put together, these effects make antipsychotics one of the strongest medication-related contributors to falls in elders.

Which Antipsychotics Increase Fall Risk the Most? A Practical Comparison

Not all antipsychotics behave the same way. Here’s a simple, easy-to-understand comparison based on real-world evidence, clinical experience and geriatric data.

1. Highest Fall Risk Group

These medications cause significant sedation, dizziness or motor stiffness:

• Haloperidol (Serenace, Haldol)
  Very high risk due to rigidity, bradykinesia and poor balance.
  Dangerous in dementia.

• Chlorpromazine (Chlorproma, CPZ)
  Heavy sedation + blood pressure drops.

• Olanzapine (Oleanz, Olanex, Zyprexa)
  Causes sedation, weight gain, diabetic risk and orthostatic hypotension.

• Quetiapine (Qutan, Quepin, Seroquel)
  Often misused for sleep; strong night-time sedation → bathroom falls.

• Clozapine (Sizopin, Clozaril)
  Causes marked dizziness, sedation, drooling, delirium. Rarely appropriate in elders.

These are the medications most commonly implicated in night-time falls, especially when elders wake up groggy to use the toilet.

2. Moderate Fall Risk Group

These drugs have less sedation but still carry significant neurological and cardiovascular risks:

• Risperidone (Risnia, Sizodon, Risperdal)
  Can cause stiffness, shuffling, tremors and stroke risk.
  Frequently used in dementia → must be monitored closely.

• Paliperidone (Invega, Paliap, Palido)
  Similar to risperidone; long-acting injections may cause prolonged motor side effects.

• Ziprasidone (Zipsydon)
  Can cause dizziness and restlessness.

• Lurasidone (Lurace, Latuda)
  Less sedating but may cause dizziness and motor changes.

3. Lower (But Not Zero!) Fall Risk Group

These may be more tolerable for some elders but still require caution:

• Aripiprazole (Arpizol, Abilify, Arip MT)
  Less sedating, lower metabolic burden.
  However, it can cause restlessness (akathisia), which can paradoxically increase falls.

• Brexpiprazole (Rexulti)
  Approved for agitation in Alzheimer’s disease in some countries.
  Early data suggests milder sedation, but long-term fall risk remains under evaluation.

• Cariprazine (Caripill, Cariprazine Sun)
  Minimal sedation but limited geriatric evidence.

No antipsychotic is “fall-safe,” but some are less destabilizing when used carefully.

How to Reduce Fall Risk When Antipsychotics Are Needed

There are situations where antipsychotics are genuinely necessary—severe aggression, hallucinations, psychosis or extreme distress. In these cases, fall prevention becomes just as important as the medication itself.

1. Start Low, Go Slow

Older adults should begin with the smallest possible dose—often one-quarter of the usual adult dose.

2. Avoid Giving Sedating Doses Late at Night

Give medications earlier in the evening so the grogginess reduces by bedtime.

3. Make Night-Time Safer

• Motion sensor lights

• Remove rugs

• Keep pathways clear

• Consider a bedside commode

4. Review Other Medications

Stopping or reducing:

• sleeping pills (zolpidem)

• benzodiazepines

• tricyclics

• antihistamines

• strong pain medicines

…often reduces fall risk more than changing the antipsychotic itself.

5. Monitor Movement, Stiffness and Blood Pressure

Regular checks can catch early changes in gait or dizziness.

6. Schedule Routine Reviews

Ask the doctor every 2–4 weeks:

“Can we reduce the dose? Can we stop it now?”

Many elders end up on antipsychotics longer than needed simply because no one proposes deprescribing.

A Better Way to Care for Older Adults

Antipsychotics should never be the first-line treatment for behavioural symptoms in dementia.
Before reaching for medication, always explore:

• pain control

• sleep structuring

• addressing constipation

• hydration

• sensory interventions

• music and routine-based therapy

• caregiver training

These strategies reduce agitation without increasing fall risk.

Medication should enter the picture only when the behaviour is dangerous, severely distressing or unmanageable with non-drug approaches.

Final Takeaway

Antipsychotics can help in select situations—but they come with a real and significant risk of falls in older adults. Understanding this risk empowers families to ask better questions, make safer decisions and create environments where elders can remain stable, mobile and dignified.

Falls are preventable. Awareness is the first step.

Dr. Srinivas Rajkumar T, MD (AIIMS), DNB, MBA (BITS Pilani)

Consultant Psychiatrist & Neurofeedback Specialist
Mind & Memory Clinic, Apollo Clinic Velachery (Opp. Phoenix Mall)
✉ srinivasaiims@gmail.com 📞 +91-8595155808