1. Why antipsychotics increase fall risk in older adults

All antipsychotics can increase fall risk through a few shared mechanisms:

• Sedation → drowsiness, slower reaction time, “heavy headed” feeling

• Orthostatic hypotension → BP drops on standing → dizziness, blackouts

• Extrapyramidal symptoms (EPS) → rigidity, bradykinesia, shuffling gait, postural instability

• Anticholinergic effects → blurred vision, confusion, delirium

• QT prolongation / arrhythmia → syncope, sudden falls

Older adults already have:

• Poorer balance

• Slower reflexes

• Polypharmacy (antihypertensives, benzodiazepines, Z-drugs, etc.)

So even a modest change in BP, gait or alertness can dramatically increase falls and fractures.

2. Broad hierarchy: which antipsychotics are “worst” for falls?

Based on observational studies and meta-analyses (mostly in older adults and dementia), a rough fall-risk hierarchy looks like this:

Highest fall risk (especially in frail elders / dementia)

• Haloperidol

  • Strong D2 blockade → marked EPS, rigidity, bradykinesia

  • Orthostatic hypotension and high overall mortality in dementia

  • Often used IM in acute agitation → prolonged post-dose sedation and motor impairment

• Chlorpromazine / other low-potency FGAs

  • Very sedating + strong anticholinergic + hypotensive

  • Classic “knocks them out” effect → dangerous in elders

• Olanzapine

  • Sedation, weight gain and orthostatic hypotension

  • Can worsen gait via metabolic and cardiovascular effects over time

• Quetiapine (counterintuitive, but important)

  • Frequently used as a “sleeping pill” in elders

  • Causes significant daytime sedation, postural hypotension and gait instability

  • Falls are a major signal in real-world data, especially at night on the way to the toilet

Intermediate fall risk

• Risperidone

  • Less sedating than quetiapine/olanzapine but:

  • EPS at higher doses → rigidity, shuffling gait

  • Orthostatic hypotension in sensitive elders

  • Also increases stroke risk in dementia, which indirectly worsens mobility

• Paliperidone

  • Similar to risperidone profile (it’s the active metabolite)

  • LAI forms can cause prolonged EPS/postural changes if dose is too high

• Lurasidone / Ziprasidone

  • Less metabolic burden, but:

  • May cause dizziness, akathisia and postural symptoms

Relatively lower fall risk (but not zero)

• Aripiprazole

  • Often less sedating

  • Lower anticholinergic burden

  • Still can cause akathisia (restlessness → erratic walking) and orthostatic hypotension in some

• Brexpiprazole / Cariprazine

  • Limited geriatric data so far

  • Mechanistically may be “gentler” on BP and weight

  • Still carry black box warning in dementia; vigilance required

• Clozapine (special category)

  • In elders, rarely used; when used, fall risk is high due to:

  • Profound sedation, orthostatic hypotension, hypersalivation, confusion

  • Plus cardiac effects (myocarditis, cardiomyopathy) and seizures

Bottom line:

No antipsychotic is fall-safe in older adults. Some are just fall-worse.

3. First-generation (typical) vs second-generation (atypical): fall risk pattern

First-generation (typical) antipsychotics (haloperidol, chlorpromazine, trifluoperazine, fluphenazine):

• Higher EPS → rigid, shuffling, stooped → classic “fall posture”

• Frequently cause orthostatic hypotension

• In dementia, associated with higher mortality and more severe adverse events

Second-generation (atypical) antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole, etc.):

• More sedation + metabolic problems, less overt EPS (except risperidone/paliperidone)

• Falls often driven by sleepiness, dizziness and nocturnal confusion

In many datasets, overall fracture and fall risk is elevated with both classes. Switching from an FGA to an SGA may change why the patient falls (EPS vs sedation), but not necessarily eliminate the risk.

4. Situational patterns: how different drugs lead to different kinds of falls

“Night-time bathroom fall” profile

• Quetiapine, Olanzapine, Chlorpromazine

• Older adult gets up at 2–3 am, sedated, hypotensive → trips or collapses

“Stiff and shuffling” fall profile

• Haloperidol, high-dose Risperidone, FGAs

• Parkinsonian gait, poor balance, freezing → slow, frequent falls

“Sudden dizzy spell/syncope” profile

• Any agent + antihypertensive + dehydration

• Orthostatic hypotension → brief loss of consciousness, head injury risk

“Agitated, restless pacing” fall profile

• Akathisia from Aripiprazole, Ziprasidone, high-dose SGAs

• Constant pacing, sudden direction changes; poor judgment → fall on obstacles

Once you recognise the pattern, you can often match it to the likely pharmacological culprit.

5. Comparative prescribing tips to reduce fall risk

If you must start an antipsychotic in an older adult, consider:

1. Indication strength

   • True psychosis or severe dangerous aggression → benefit may outweigh risk.

   • Mild sundowning or caregiver inconvenience → risk likely outweighs benefit.

2. Dose discipline

   • Start at ¼–½ of usual adult starting dose.

   • Titrate slowly; never chase behaviours with aggressive dose jumps.

3. Drug choice by phenotype

   • Marked rigidity / Parkinson’s / Lewy body dementia:

     • Avoid haloperidol and other high-EPS drugs.

     • If absolutely necessary, very low-dose quetiapine or clozapine (only with monitoring) is usually preferred — but falls must be anticipated and mitigated.

   • Very frail, osteoporotic, recurrent faller:

     • Avoid “sledgehammer sedation” (quetiapine high-dose, olanzapine at night, chlorpromazine).

     • If psychosis is clear, consider low-dose risperidone or aripiprazole, monitor gait and BP closely.

   • Orthostatic hypotension or autonomic dysfunction:

     • Avoid chlorpromazine, clozapine, high-dose quetiapine/olanzapine.

     • Regularly check lying–standing BP and review cardio meds.

4. Polypharmacy clean-up

   • Every time you add an antipsychotic, re-check:

     • Benzodiazepines

     • Z-drugs (zolpidem, zopiclone)

     • Tricyclics

     • Anticholinergics

     • High-dose antihypertensives

   • Often you can reduce fall risk more by deprescribing these than by fine-tuning antipsychotic choice.

5. Scheduled falls review

   • Within 1–2 weeks of starting or increasing an antipsychotic in an older adult, specifically ask:

     • Any slips, trips, “near-falls”?

     • Light-headedness on standing?

     • New shuffling or stiffness?

   • If yes, either reduce dose, change timing (e.g., earlier evening), or consider an alternative.

6. Non-drug fall protection when antipsychotics are unavoidable

If an older adult genuinely needs an antipsychotic:

• Timing: Give the sedating dose earlier in the evening, not right at bedtime.

• Night-lighting: Motion-sensor lights or faint LED strip lighting to bathroom.

• Toilet access: Commode near bed; clear pathway, no loose rugs.

• Footwear: Non-slip slippers or sandals, never socks alone on smooth floors.

• Physiotherapy: Balance and strength training to build protective reflexes.

• Assistive devices: Walking stick, walker, grab bars near bed and toilet.

• Family education: Warn them explicitly: “For the next few weeks, fall risk is higher. Watch closely.”

7. How to discuss this with families (and yourself)

A simple, honest script approach:

• “This medicine may help reduce the distressing behaviour, but it also increases the risk of falls and fractures.”

• “We will use the lowest dose for the shortest time, and we will review regularly.”

• “If you see new stiffness, extra sleepiness, or unsteadiness, tell us immediately—we may need to reduce or stop it.”

This reframes antipsychotics as powerful but risky tools, not routine “sleep tablets” for elders.

8. Take-home comparative summary (clinician mental model)

• Worst for falls: Haloperidol, Chlorpromazine, high-dose Quetiapine, Olanzapine, Clozapine

• Moderate risk: Risperidone, Paliperidone, Ziprasidone, Lurasidone

• Relatively lower (but still real) risk: Aripiprazole, Brexpiprazole, Cariprazine

• Class effect: All antipsychotics increase falls and fractures in older adults; choice can only modify the risk, not remove it.

For practice, the magic is less in which antipsychotic you choose and more in whether you truly need one, how low you go, how slowly you titrate, and how aggressively you de-risk the environment and co-medications.