Multidisciplinary and Interdisciplinary Collaboration in Comprehensive Geriatric Assessment: Building the Bigger Picture Together
Author: Heli-Maria Huusko, Specialist in Gerontological Nursing, Wellbeing Services County of Southwest Finland (Varha)
Comprehensive Geriatric Assessment (CGA) helps healthcare professionals see the bigger picture of an older person’s situation. Health status, functional ability, medication, nutrition, mental wellbeing, social circumstances and environmental safety all provide important information. But how can these different perspectives be brought together to create a shared understanding of the older person’s situation?
The answer lies in collaboration.
Older adults rarely face challenges in only one area of life. A decline in mobility may increase the risk of social isolation. Medication-related problems can affect both physical and cognitive functioning. Chronic diseases, functional limitations, emotional wellbeing, and social circumstances often interact in complex ways. Looking at only one aspect may provide an incomplete picture, while understanding the connections between these factors helps professionals identify the real needs of the individual.
For this reason, Comprehensive Geriatric Assessment is built on multidisciplinary and interdisciplinary collaboration. Its goal is not simply to collect separate assessments from different professionals, but to create a holistic understanding of the older person’s strengths, needs and goals.
Multidisciplinary or Interdisciplinary Collaboration?
The terms multidisciplinary and interdisciplinary collaboration are often used interchangeably, but they describe different approaches.
In multidisciplinary collaboration, professionals from different disciplines contribute their expertise independently. A physiotherapist may assess mobility, a pharmacist may review medications, and a social worker may evaluate social support needs. Each professional provides valuable information from their own perspective.
Interdisciplinary collaboration goes a step further. Professionals actively share information, discuss findings and combine their expertise to develop a common understanding of the person’s situation. Rather than working alongside one another, they work together toward shared goals.
In CGA, this integrated approach is particularly important. The needs of older adults are often interconnected, and effective care planning requires professionals to see beyond the boundaries of their own disciplines. By combining perspectives, the team can better understand how different factors influence one another and how care decisions may affect the older person’s everyday life.
The Importance of a Coordinated Team
The composition of the CGA team varies depending on the setting and the individual’s needs. In many cases, the assessment begins with a core team consisting of a registered nurse and a geriatrician. Additional professionals, such as physiotherapists, occupational therapists, pharmacists, social workers or other specialists, may participate when their expertise is needed.
The effectiveness of the team depends not only on professional knowledge but also on coordination. Shared goals, clear roles and a common understanding of the assessment process help ensure that everyone is working toward the same outcome. The focus should always remain on the needs of the older person rather than on professional boundaries.
The Significant Role of Nursing
Registered nurses play a central role in Comprehensive Geriatric Assessment. In some care settings, CGA may even be nurse-led.
Nurses are often the professionals who spend the most time with the older person throughout the assessment process. They gather information through interviews, observation and clinical assessment. They evaluate functional ability, monitor vital signs, assess daily activities and contribute to care planning. In many situations, nurses also coordinate the assessment process and facilitate communication among team members.
Nursing expertise brings a unique perspective to CGA. Nurses focus not only on disease management but also on health promotion, illness prevention, functional capacity, medication management and fall prevention. Equally important is their ability to connect information from multiple sources and translate assessment findings into meaningful, person-centred care plans.
Family Members and Caregivers as Essential Partners
A comprehensive assessment should not rely solely on professional observations. Family members and caregivers often have valuable insights into the older person’s daily life, routines and recent changes in health or functioning.
Their involvement can improve the quality of information available to the team and support continuity of care once the assessment has been completed. Family caregivers are not merely sources of information; they are important partners in the assessment process. Their perspectives help professionals better understand how health-related challenges affect everyday life and what kinds of support may be needed in the future.
Challenges and Good Practices
Successful collaboration is not always straightforward. Common challenges include difficulties in information sharing, disagreements regarding care decisions, unclear professional responsibilities and the absence of shared patient information systems.
Several practices can strengthen interdisciplinary collaboration:
- Regular team meetings and discussions
- Shared goals and common understanding of the assessment process
- Clear roles and responsibilities
- Open communication between professionals
- Active involvement of older adults and their caregivers
When these elements are present, collaboration becomes more effective and supports better decision-making.
Seeing the Whole Picture
Seeing the bigger picture is at the heart of Comprehensive Geriatric Assessment. By bringing together different professional perspectives, multidisciplinary and interdisciplinary collaboration creates a shared understanding of an older person’s strengths, needs and goals.
No single professional can see the whole picture alone. However, when healthcare professionals, older adults and their caregivers work together, individual observations become a shared understanding. This collective approach helps identify unmet needs, supports person-centered care and enables better outcomes for older people.
Ultimately, multidisciplinary and interdisciplinary collaboration are not simply methods of working. They are fundamental principles of Comprehensive Geriatric Assessment, ensuring that older adults are seen not as a collection of individual problems, but as whole person with unique needs, strengths and life circumstances.
Keywords:
CGA, comprehensive geriatric assessment, teamwork, multidisciplinary collaboration, interdisciplinary collaboration, shared understanding, older adults
References:
Bakerjian, D. 2024. Geriatric Interdisciplinary Teams. https://www.msdmanuals.com/professional/geriatrics/providing-care-to-older-adults/overview-of-geriatric-care
Brent, L., Spirgienė, L., O’Regan, N., & Diggin, B. (2023). The Nursing Role in Orthogeriatric Comprehensive Geriatric Assessment (CGA). In Fragility Fracture and Orthogeriatric Nursing: Holistic Care and Management of the Fragility Fracture and Orthogeriatric Patient (pp. 95-110). Cham: Springer International Publishing.
Choi, J. Y., Rajaguru, V., Shin, J., & Kim, K. I. (2023). Comprehensive geriatric assessment and multidisciplinary team interventions for hospitalized older adults: A scoping review. Archives of gerontology and geriatrics, 104, 104831.
Chen, Z., Ding, Z., Chen, C., Sun, Y., Jiang, Y., Liu, F., & Wang, S. (2021). Effectiveness of comprehensive geriatric assessment intervention on quality of life, caregiver burden and length of hospital stay: a systematic review and meta-analysis of randomised controlled trials. BMC geriatrics, 21, 1-14.
Ellis, G. & Sevdalis, N. (2019). Understanding and improving multidisciplinary team working in geriatric medicine. Age ond Ageing, 48: 498–505.
Liu, X., Song, L., Xiao, S., & Wang, Y. (2023). Comprehensive geriatric assessment, multidisciplinary treatment, and nurse-guided transitional care in hospitalized older adults: a randomized controlled trial. Research in Gerontological Nursing, 16(5), 224-230. https://journals.healio.com/doi/10.3928/19404921-20230606-03
Safari, R., Jackson, J., Boole, L. (2023). Comprehensive geriatric assessment delivered by advanced nursing practitioners within primary care setting: a mixed-methods pilot feasibility randomised controlled trial. BMC Geriatrics 23: 513 (2023). https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-023-04218-0
Taberna, M., Gil Moncayo, F., Jané-Salas, E., Antonio, M., Arribas, L., Vilajosana, E., … & Mesía, R. (2020). The multidisciplinary team (MDT) approach and quality of care. Frontiers in oncology, 10, 85. https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2020.00085/full