Background: From a geriatric perspective, the use of antipsychotic drugs (AP) is associated with significant risks in addition to their known effects. These include unfavorable interactions with geriatric syndromes, such as immobility and risk of falling, and potentially increased mortality, at least in certain patient groups. With reference to this the current state of knowledge on treatment with AP in older people with schizophrenia spectrum disorders is summarized with a focus on the typical multimorbidity of geriatric patients. Methods: Narrative review with special consideration of guidelines and consensus papers from German speaking countries and a PubMed-supported literature search for current systematic reviews and meta-analyses. Results: Antipsychotic agents are an essential part of a comprehensive treatment concept for schizophrenia with well-documented evidence. In geriatric patients adaptations under gerontopharmacological aspects are necessary. A sufficient data basis for evidence-based recommendations for the treatment of multimorbid and frail geriatric patients does not exist. Conclusion: An effective and as safe as possible treatment with AP requires a careful risk-benefit assessment, combined with an individual adaptation regarding the substance applied, dose and treatment duration in an interdisciplinary/multiprofessional context.