7 Old age psychiatry7.2 Principles of service provision
7.2.1 Multidisciplinary care for older people
2 min read
Written by Resident Doctor Committee · Published
New in the 2027 syllabus
The College added this topic for exams from January 2027.
One account of the person's needs
Assessing an older adult covers much more than the mental state. It brings together:
mental state and cognition
physical health and medicines
function (what the person can manage day to day)
living conditions
the person's own priorities.
A multidisciplinary team pulls these different observations into one formulation and one plan. Several professionals each doing their own separate assessment is not the same thing. On its own, that does not coordinate care.
Find out the person's baseline function, meaning what they could do before this episode. This tells you whether a loss of ability is recent or a longstanding disability. It also helps you set realistic rehabilitation goals.
Team member | Contribution |
|---|---|
Psychiatry and mental health nursing | Mental illness, cognition, risk, treatment and ongoing observation |
Geriatric medicine and primary care | Physical illness, frailty and continuity of medical care |
Occupational therapy and physiotherapy | Daily activities, safety at home, mobility and falls |
Speech and language therapy and dietetics | Communication, swallowing and nutrition |
Social work and pharmacy | Care needs, safeguarding, medicines reconciliation and treatment burden |
Making the plan work
Involve the person. Use sensory aids such as glasses or hearing aids, an interpreter or adapted information as needed. Being old or having dementia does not take away their voice.
Ask the carer. Carers can often tell you what has changed in sleep, eating and function. Assess the carer's own needs separately.
Name a coordinator. One person keeps track of actions and contacts. Each task has a responsible professional and a review date.
Plan transitions. When someone moves between hospital, home and care home, agree a medicines list, arrange follow-up and make clear who is responsible for any outstanding results.
Take refusing meals as an example. It may reflect depression, tooth pain, dysphagia (difficulty swallowing), difficulty recognising food or an unfamiliar environment. The team checks each of these explanations before treating the behaviour as a psychiatric symptom alone.
Reviewing outcomes
Function and comfort may improve even when a cognitive score does not. Review eating, mobility, distress and the activities the person values, not just the test score.
Agree an escalation plan. It sets out what a carer or care home should do after a sudden change, including when the person needs urgent medical assessment.