Finnish registry data spanning 57,005 community-dwelling older adults reveals cardiovascular disease and stroke as the strongest predictors of off-label antipsychotic prescribing, independent of approved psychiatric indications. The analysis identified distinct prescribing patterns: women with non-psychotic conditions received off-label antipsychotics more frequently, while men were more likely to receive them compared to those with established psychotic disorders requiring standard treatment. This finding illuminates a concerning prescribing trend where physical health complications, rather than psychiatric symptom severity, may drive medication decisions. The cardiovascular association suggests physicians may be prescribing antipsychotics for agitation or behavioral symptoms secondary to vascular cognitive impairment, despite limited evidence for efficacy and known metabolic risks. The higher opioid co-prescribing in off-label users points to complex pain-behavior interactions that warrant investigation. Given antipsychotics carry FDA black box warnings for dementia-related mortality and can worsen cardiovascular outcomes, this prescribing pattern represents a potential mismatch between risk and benefit. The study's exclusion of Alzheimer's patients makes these cardiovascular associations particularly noteworthy, suggesting off-label use extends beyond traditional dementia-related behavioral management into broader geriatric care contexts where evidence-based alternatives may be preferable.