Falls are the leading cause of fatal and nonfatal injury in adults over 65 in the United States, according to the CDC. Antipsychotic medications are repeatedly identified as one of the strongest medication-related risk factors. For older adults with schizophrenia who depend on antipsychotic treatment, the question isn't whether to use the medication — it's how to use it as safely as possible.
Antipsychotics increase fall risk through orthostatic hypotension, sedation, parkinsonism, and cognitive effects — all of which can be reduced through careful dosing, monitoring, and environmental modification.
How antipsychotics cause falls
Orthostatic hypotension
Many antipsychotics block alpha-adrenergic receptors, which causes blood pressure to drop on standing. The drop is often most marked in the first weeks after starting or after dose increases, and after taking the medication. It can also be exacerbated by dehydration, heat, alcohol, and other antihypertensive medications.
Sedation
Sedating antipsychotics (quetiapine, olanzapine, clozapine, low-potency first-generation antipsychotics) can leave older adults groggy, especially in the first hours after a dose. Night-time bathroom trips become high-risk events.
Parkinsonism and gait change
Dopamine D2 blockade can produce shuffling gait, reduced arm swing, postural instability, and slowed reactions — all classic risk factors for falling. Higher-potency D2 blockers (haloperidol, risperidone at higher doses, paliperidone) are particularly likely to cause this.
Cognitive effects
Anticholinergic activity, sedation, and the underlying illness can all reduce attention and reaction time, making it harder to recover from a stumble.
QT prolongation and syncope
Some antipsychotics prolong the QT interval. Rarely, this leads to a brief loss of consciousness — and a fall.
Other contributors that interact with antipsychotics
- Benzodiazepines and Z-drugs
- Opioids
- Antihypertensives, especially when over-titrated
- Diuretics, particularly with dehydration
- Anticholinergics (added to manage parkinsonism, paradoxically often making falls worse)
- Tricyclic antidepressants
How to assess fall risk
A practical fall risk assessment for an older adult on antipsychotics includes:
- Fall history — any fall in the past year, near-falls, fear of falling
- Orthostatic vital signs — blood pressure and heart rate lying, sitting, and standing at 1 and 3 minutes
- Gait and balance assessment — Timed Up and Go test, 30-second chair stand, or full Berg Balance scale
- Vision check — last eye exam, glasses up to date
- Hearing check
- Foot exam and footwear assessment
- Home safety assessment — rugs, lighting, bathroom grab bars, stair handrails
- Medication review against the Beers Criteria
What helps
Medication strategies
- Use the lowest effective antipsychotic dose
- Avoid abrupt dose changes
- Choose lower-risk medications when clinically reasonable (aripiprazole, lurasidone, low-dose quetiapine often have fewer orthostatic effects than risperidone, olanzapine, or older agents)
- Avoid adding anticholinergics — manage parkinsonism by lowering the antipsychotic dose or switching when possible
- Minimise benzodiazepines and Z-drugs
- Review every other medication for fall risk contribution
Behavioural strategies
- Stand up slowly — sit on the edge of the bed for 30 seconds before rising
- Hydrate adequately
- Take sedating doses at bedtime
- Use a bedside commode at night to avoid long bathroom trips
- Keep nightlights on key paths
- Limit alcohol
Environmental strategies
- Remove throw rugs
- Install grab bars in bathrooms
- Add handrails on both sides of stairs
- Improve lighting, especially in hallways
- Wear well-fitting non-slip footwear
Strength and balance training
Tai chi, Otago exercises, and structured strength training have all been shown to reduce falls in older adults. They are appropriate adjuncts in older adults with schizophrenia, often with adaptations for cognitive and motor symptoms.
An older adult on antipsychotics has a fall — even one that looks minor. Falls often signal a medication problem, an undiagnosed medical issue (infection, dehydration, cardiac arrhythmia), or a need to reassess the regimen. Any fall with loss of consciousness needs same-day evaluation.
The trade-off
For someone with schizophrenia who needs ongoing antipsychotic treatment, the goal is not zero fall risk — it's the lowest achievable risk consistent with mental stability. A relapse of psychosis is itself a major fall risk (through agitation, dehydration, and disrupted sleep), so simply lowering the antipsychotic to vanishing doses is rarely the right answer. Skilled geriatric psychiatry is largely the art of finding the right balance.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.