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Understanding and Responding to Pisa Syndrome (Leaning to One Side) in Dementia

If your loved one with dementia or Parkinson's disease has started leaning noticeably to one side while sitting or walking, it may be Pisa syndrome—a condition that looks like the Leaning Tower of Pisa. This is not just aging or poor posture; it can be caused by medication side effects, changes in the brain's sense of balance, or the dementia itself. The good news is that there are concrete, practical steps you can take to help, from adjusting medications with your doctor to making simple home safety changes. You are not powerless, and noticing this change early is your first powerful step.

Key points

  • Pisa syndrome is a real, treatable condition—not just aging or poor posture.
  • Medications are a common cause, especially donepezil (Aricept), antipsychotics, and Parkinson's drugs. Many people improve when the medication is adjusted.
  • Do not stop or change any medication without a doctor's approval.
  • Physical therapy, home safety changes, and supportive seating can make a big difference.
  • You are the first line of defense—your observations are crucial for the medical team.
  • Stay hopeful: with the right steps, leaning can often be reduced or managed safely.

What Is Pisa Syndrome and Why Does It Happen?

Pisa syndrome is a condition where a person's upper body leans persistently to one side, either when sitting or walking. It is named after the Leaning Tower of Pisa because of the visible tilt. While it is not extremely common, it does occur in people with dementia—especially those with Parkinson's disease or Lewy body dementia—and it can also be triggered by certain medications. The leaning is not a choice or a sign of stubbornness; it reflects changes in the brain's ability to sense and control body position.

One major cause is medication. A 2024 study of 191 cases found that Alzheimer's medications like donepezil (brand name Aricept), antipsychotics prescribed for mood or agitation, and Parkinson's disease medications can all trigger Pisa syndrome. In over half of those cases, the symptoms started within one month of starting or changing a medication. The encouraging news is that many people improve when the medication dose is lowered or stopped, but this must be done under a doctor's supervision.

Another factor is the brain's distorted sense of balance. Some people with dementia actually lean to one side but feel perfectly straight, while others walk straight but feel as if they are leaning. This disconnect happens because the brain's visual input and internal balance signals become misaligned. For example, if the brain relies too heavily on faulty visual cues, the person may unconsciously tilt to compensate for a perceived imbalance that isn't real. This is why simply telling someone to 'stand up straight' rarely works—they genuinely believe they are already upright.

How Different Dementias and Stages Affect Leaning

The type and stage of dementia influence how Pisa syndrome shows up and what you can do about it. In Parkinson's disease dementia, the leaning is often linked to the motor symptoms of Parkinson's—rigidity, slowness, and gait changes—and to the dopamine-related medications used to treat them. In Lewy body dementia, which shares many features with Parkinson's, leaning may appear alongside visual hallucinations and fluctuating attention. In Alzheimer's disease, leaning is more likely to emerge in later stages when the brain damage has spread to areas controlling basic bodily functions like walking and swallowing. At that point, the person may spend most of their time in a wheelchair or bed, and leaning becomes a safety concern for pressure sores and falls.

It is also important to know that many older adults have mixed dementia—for example, a combination of Alzheimer's, vascular dementia, and Lewy body disease. This means the causes of leaning can be multiple and overlapping. A person over 80 with dementia often has more than one brain change contributing to their symptoms. Additionally, depression is very common in dementia and can make leaning worse because it reduces motivation to move or correct posture. Addressing mood can sometimes improve physical symptoms.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Document the leaning pattern (onset, side, sitting/walking, associated symptoms) for the doctor.

  2. Ask the prescriber to review medications—specifically donepezil, antipsychotics, and Parkinson's drugs—as a potential cause; many improve within weeks of adjustment.

  3. Request a physical therapy evaluation from a neurologically-experienced therapist to assess balance, strength, and prescribe targeted exercises.

  4. Reduce fall risk: clear walkways, remove loose rugs, add nightlights, install grab bars at toilet and shower, and use a firm chair with elbow-height armrests.

  5. Use supportive seating: for wheelchairs, ask an occupational therapist about lateral trunk supports or a tilt-in-space chair; for chairs, place a wedge on the non-leaning side to gently nudge upright.

  6. Use calm repositioning cues: stand on the leaning side, place a light hand on shoulder or hip, say 'Let's straighten up together,' and wait for their response.

  7. Check vision: keep glasses current and, for vision-related dementias, ask an occupational therapist about aids for depth perception.

  8. Monitor for worsening leaning, pain, redness, or skin breakdown on the leaning side, and report promptly to the care team.

What not to do

  • Don't repeatedly tell them to 'stand up straight' or physically force them upright—they likely feel upright, and this causes agitation or injury.

  • Don't stop or change any medication on your own; sudden withdrawal (e.g., donepezil, antipsychotics) can be dangerous.

  • Don't dismiss the leaning as 'just aging'—it may be a treatable medication effect or neurological change.

  • Don't assume it's permanent; many cases improve with medication adjustment, therapy, or environmental modifications.

  • Don't overlook pain—leaning may compensate for an old injury, arthritis, or pressure sore; ask gently and watch for grimacing.

Practical tools

  • Medication & Symptom Log

    A notebook or phone note recording every medication (name, dose, start date), daily leaning observations (time, side, activity), and any falls or new symptoms; bring to every appointment.

  • Supportive Seating Setup

    Firm chair with armrests at elbow height, a rolled towel or foam wedge on the non-leaning side; for wheelchairs, request lateral trunk supports or a tilt-in-space chair from an occupational therapist.

  • Fall-Prevention Checklist

    Install grab bars at toilet and shower, use a shower chair, remove throw rugs, widen pathways for a walker, and add nightlights in hallways and bathrooms.

  • When to Call the Doctor Trigger List

    Posted list of red flags: sudden increase in leaning, new pain, redness/skin breakdown on leaning side, a fall, new confusion or dizziness, or any medication change in the past month.

  • Vision Check Reminder

    Annual eye exam (more frequent if posterior cortical atrophy), keep glasses clean and accessible, ask occupational therapist about high-contrast markers or visual aids for spatial awareness.

Discuss with your clinician

Ask your doctor: 'Could my loved one's leaning be caused by donepezil (Aricept), an antipsychotic, or a Parkinson's medication? Is it safe to lower the dose or switch to an alternative?'

Ask: 'Should we consider a physical therapy evaluation specifically for balance and leaning?'

Ask: 'Are there any other medical conditions—like a stroke, inner ear problem, or spinal issue—that could be causing this leaning?'

Ask: 'If the leaning is severe and does not improve, is deep brain stimulation or any other procedure an option for my loved one?'

Ask: 'How can we monitor for pressure sores or falls related to the leaning, and what should I do if I see skin redness or a fall?'

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