Mental Health and Cognitive Impairment in Podiatry: Reflections From the APMA National

Key Takeaways 

• Look beyond "nonadherence." Depression, anxiety, cognitive impairment, low health literacy, social barriers, and limited support systems may underlie challenges with treatment adherence, making it essential to assess the reasons behind a struggling care plan rather than assigning blame.  

• Use brief, compassionate conversations to build trust. Asking permission, normalizing discussions about mood and memory, focusing on healing and function, and avoiding stigmatizing language can help podiatrists address sensitive topics while preserving the patient-provider relationship.  

• Screen when it changes care—and coordinate support. Practical tools such as the PHQ-2, GAD-2, and Mini-Cog, combined with teach-back techniques, simplified care plans, and established referral pathways to primary care, behavioral health, social work, rehabilitation, and other specialists, can improve patient safety, adherence, and outcomes. 

What are some of the most important mental health or cognitive impairment signs podiatrists should recognize during routine visits, and how can they address these concerns in a way that feels both compassionate and appropriate?   

Mental health and cognitive impairment often show up in podiatry as “nonadherence,” but the presentation may actually reflect depression, anxiety, pain catastrophizing, memory problems, low health literacy, lack of support, or unsafe home circumstances. A helpful framing from the presentation is the “3 barriers” model: when a care plan is failing, ask whether the patient can’t do it, can’t access/afford it, or won’t/isn’t ready because of fear, depression, substance use, mistrust, or other barriers.   

The key is to avoid making the patient feel blamed or labeled. Tie the conversation directly to the shared podiatric goal: healing, safety, function, and independence. 

Examples: 

• “I’m asking because mood, sleep, stress, and memory can affect wound healing and how easy it is to follow a care plan.” 

• “This is not about blaming you. It helps me understand what support would make the plan more doable.” 

• “Your pain is real. Stress and mood can amplify pain signals and affect healing routines.” 

• “These are common health issues that affect recovery.”  

Many clinicians worry about saying the "wrong thing" when discussing mental health or cognitive changes with patients. What communication strategies have you found to be most effective for starting these conversations while maintaining trust and preserving the patient-provider relationship? 

Clinicians often fear saying the “wrong thing,” but the presentation emphasizes that the safest strategy is to be brief, direct, normalizing, and connected to the patient’s foot-care goals. 

Core Communication Principles 

Use 4 steps: 

1. Ask permission 
   “Would it be okay if I ask a few questions about mood, stress, sleep, and memory?” 

2. Normalize the issue 
   “Many people dealing with pain, diabetes, wounds, surgery recovery, or limited mobility experience changes in mood, sleep, or memory.” 

3. Focus on function and safety 
   “I ask because these things can affect healing, wound care, offloading, medications, and fall risk.” 

4. Avoid labels early 
   Use concrete observations: “I’ve noticed it’s been hard to keep track of dressing changes,” rather than “You’re noncompliant” or “You seem cognitively impaired.” 

A useful script from the presentation could sound like this: 

“To help your foot heal and keep you safe, I ask many patients briefly about mood, stress, and memory. Is it okay?” 

Then ask: 

“In the last two weeks, how often have you felt down, depressed, or hopeless?” 
“How often have you had little interest or pleasure in doing things?” 
“Any trouble remembering steps for your care plan or keeping track of medications or appointments?” 

Then close with: 

“Thank you. Based on this, I’d like to adjust the plan and connect you with support.” 

Handling Pushback 

Patients may worry that their symptoms are being dismissed or that they are being labeled. The presentation gives helpful responses: 

Patient: “Are you saying it’s all in my head?” 
Response: “No—your pain is real. Mood and stress can amplify pain signals and affect healing routines.” 

Patient: “I’m not crazy.” 
Response: “I’m not labeling you. These are common health issues that affect recovery.” 

Patient: “I don’t want psychiatry.” 
Response: “We can start with what feels acceptable—sleep support, counseling, medication review, or practical home-care help.” 

This preserves trust because the clinician is not forcing a psychiatric identity onto the patient. The clinician is saying: “I want to make your foot-care plan safer and more successful.” 

When a podiatrist identifies concerns about a patient's mental health or cognitive function, what practical next steps should they take? Can you discuss the role of interdisciplinary collaboration and any resources or referral pathways that clinicians should have in place? 

The goal is to screen briefly, assess safety and function, adjust the podiatric care plan, document, and connect the patient to the right support. 

Step 1: Use rapid screening tools when they change care 

The presentation emphasizes: do not screen everyone for everything—screen when it changes care. 

Useful tools include: 

• PHQ-2 for depression screening 
  If positive, consider PHQ-9. 

• GAD-2 for anxiety screening 
  If positive, consider GAD-7. 

• Mini-Cog when there are concerns about cognition, such as repeated confusion, missed steps, medication errors, unreliable history, or unsafe self-care. 

• MoCA if a more detailed cognitive screen is needed after a positive Mini-Cog or ongoing concern. 

Step 2: Assess whether the patient can safely perform key care tasks 

For cognitive or functional concerns, use “capacity checks” that are practical and podiatry-specific: 

• “Walk me through how you’ll do the dressing change tonight.” 

• “Show me how you’ll use the boot or offloading shoe.” 

• “What will you do if you see increased redness, drainage, or fever?” 

Best practice is teach-back plus demonstration, not simply repeating verbal instructions. Provide: 

• One-page written or pictorial instructions 

• Fewer steps 

• Labeled supplies 

• Clear follow-up timing 

• Caregiver involvement when appropriate and with consent 

Step 3: Adjust the podiatric care plan 

If mood, cognition, or social barriers are affecting care, make the plan more doable: 

• Simplify wound-care routines 

• Reduce the number of steps 

• Arrange closer follow-up 

• Involve a caregiver or helper 

• Consider home health nursing 

• Use pharmacy blister packs or medication review 

• Reassess footwear/offloading feasibility 

• Address pain and sleep 

• Set function-based goals 

• Coordinate PT/OT for mobility, balance, fall prevention, or assistive devices 

For example, in a diabetic foot ulcer patient with cognitive impairment, the plan may need to shift from “daily independent dressing changes” to “home health dressing changes plus caregiver teach-back and weekly wound checks.” 

Step 4: Know when to escalate urgently 

Safety is essential. 

If a patient endorses self-harm thoughts, ask directly about: 

• Plan 

• Intent 

• Means 

If imminent risk is suspected: 

• Do not leave the patient alone 

• Activate the site protocol 

• Involve emergency department, psychiatry, crisis response, or local emergency services as appropriate 

• Document clearly 

Also escalate urgently for: 

• Suspected delirium 

• New acute confusion, especially inpatient or post-op 

• Inability to safely self-manage a wound or offloading device 

• Unsafe discharge situation 

• Severe functional impairment 

• Suicidality 

• Uncontrolled pain or itch 

• Recurrent infection with inability to follow care plan 

A key hospital pearl from the presentation: new confusion in the hospital or post-op setting should be treated as delirium until proven otherwise and escalated to the primary team. 

Step 5: Build interdisciplinary referral pathways 

The most effective approach is coordinated care. Depending on the issue, podiatrists should have referral pathways to: 

• Primary care for depression, anxiety, cognitive concerns, medication review, and chronic disease coordination 

• Behavioral health/psychology/psychiatry for depression, anxiety, trauma symptoms, suicidality, severe distress, CBT/ACT, or medication management 

• Social work for transportation, housing instability, food insecurity, insurance barriers, caregiver support, and home safety 

• Case management/care coordination for complex wounds, missed visits, discharge planning, and high-utilization patients 

• Home health nursing for wound care, medication support, and monitoring 

• PT/OT for gait, balance, fall prevention, assistive devices, offloading adherence, and functional training 

• Pharmacy for polypharmacy, sedating medications, renal dosing, blister packs, and medication adherence 

• Vascular surgery for PAD/CLTI and limb-preservation care 

• Endocrinology/diabetes care teams for diabetes-related foot disease and glycemic management 

• Nephrology/dialysis teams for ESRD-related cognitive, medication, and psychosocial issues 

• Dermatology for severe inflammatory or infectious dermatologic foot disease 

• Neurology/geriatrics/neuropsychology when cognitive impairment, dementia, or complex neurologic disease is suspected 

The presentation’s outpatient workflow is especially practical: 

• Triggers: recurrent ulcers, chronic pain, repeated no-shows, post-op nonadherence 

• Team process: MA/nurse screens → provider addresses → coordinator schedules referrals 

• Close the loop: follow-up plan plus documentation 

In the hospital setting, a useful checklist includes: 

• Cognition/capacity 

• Available supports 

• Discharge feasibility 

• Early involvement of case management, social work, PT/OT, and pharmacy 

Dr. Priesand is a dually appointed Clinical Associate Professor of Surgery in the Division of Vascular Surgery and Internal Medicine in the Division of Metabolism, Endocrinology, and Diabetes at the University of Michigan Medical School.