Facilitating Sustainable Behavior Change in Cognitive Decline
What Rehab Professionals Need to Know
"She paused. She looked at me for a second or two and said, 'I don't know.'"
Physical and occupational therapists spend more one-on-one time with patients than almost any other clinician in the healthcare system.
Yet, as physical therapist and functional medicine health coach Julianne Reinstein, MS, PT, argue in their August 26th event, that time is routinely spent on the musculoskeletal complaint that brought the patient in the door while a much bigger opportunity to protect the patient's brain health goes unaddressed.
Reinstein, who has spent over 30 years in outpatient orthopedic practice and more recently trained as a National Board-Certified Health and Wellness Coach and Functional Medicine Certified Health Coach, has built a framework for closing that gap: combining motivational interviewing with functional medicine's lifestyle-based approach to give rehab professionals practical tools for supporting patients with, or at risk for, cognitive decline.
A Personal Reason for the Work
Reinstein's path into this material wasn't academic. It started when her daughter, previously healthy, became chronically ill while away at college. Infection after infection, hair loss, weight gain, and insomnia that conventional medicine could only answer with a metformin prescription. That search for a better answer led Reinstein to the Functional Medicine Coaching Academy, a 12-month program she began even as her family was hit by successive crises: her father passed away one month in, and five weeks later, her mother suffered a hemorrhagic stroke.
Reinstein's mother had already been diagnosed with mild cognitive impairment at 74. After the stroke, followed by a COVID infection and heart failure, her decline accelerated sharply, turning what had been a professional curiosity into what Reinstein now calls one of her deepest passions.
A photo of her mother and daughter together, taken while packing up the Buffalo lake house her mother could no longer safely live in alone, captures why this material matters to her personally: her mother, who had forgotten she'd ever graduated from college, watches her granddaughter try on an outfit while holding a small graduation gift Reinstein had saved for the moment. "I look at this," she said, "and this is my why. And this is what has pushed me through everything I have gone through in the last three years, and is one of the reasons why I wanted to give this presentation tonight."
Functional Medicine's Different Starting Point
To understand Reinstein's approach, it helps to understand how she distinguishes functional medicine from the conventional model most healthcare professionals were trained in.
"Functional medicine steps in where conventional medicine ends," she explained. "It focuses on why people get ill and identifies the underlying or root cause of the disease, and then personalizes the care for the individual patient." Conventional medicine remains essential for acute crises but isn't built to resolve chronic conditions like diabetes, dementia, or heart disease: "It's not collaborative. It's physician led... it's more reactive medicine, and the lifestyle changes are secondary, oftentimes not discussed at all." Functional medicine, by contrast, "is more collaborative... it involves the patient" and takes a systems-biology view, treating the whole person. "It's proactive, it gets down to the root cause of the disease, empowers the patient, and guides them towards better health," she said, "often achieving lasting wellness."
Functional medicine health coaching sits inside that model as a distinct role. A functional medicine practitioner (like a physician, nurse practitioner, or physician assistant) orders labs and testing; the health coach works alongside the patient to translate that into sustainable behavior change. As Reinstein put it in the session, health coaches "do not diagnose medical conditions or prescribe treatments. Instead, we act as supportive partners in facilitating positive changes for individuals' overall wellbeing."
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Starting With "Why"
Long before getting into specific interventions, Reinstein anchors the entire model in a single, deceptively simple question: why does this patient want to make a change in their health? "I'm sure no medical practitioner has ever asked them what they wanted their health for," she said. "It's a powerful question when you really think about it."
She encourages clinicians to build this into ordinary sessions. "While you're arranging their knee, you can have a two-minute discussion... what is their vision?" she said. "How do they want to get out of bed when they're 85 years old?"
That "health vision" becomes something a patient can return to on the days motivation runs low: "You try to reach for that vision when you're tired and you don't want to exercise, or you just want to grab that donut." Reinstein said she's used this extensively with her own teenage scoliosis patients: "I have seen really incredible change in them once they start thinking about what do they want to be like when they're my age, when they're in their 50s."
Motivational Interviewing for a Uniquely Difficult Population
Once a patient's "why" is established, motivational interviewing becomes the tool for sustaining it, particularly for a population Reinstein describes as uniquely resistant to conventional coaching.
"Motivating our patients, especially those with cognitive decline, can be extremely challenging. I've learned this with my own mother — I get the eye roll when I ask her if she's gone and done her exercises today." Patients often carry the misconception that nothing can be done to change their trajectory, and according to Reinstein, "this is completely false."
Reinstein illustrated this with her own mother's case: After refusing eight consecutive physical therapy sessions, her mother's therapist was ready to discharge her. Reinstein suggested something simple: since her mother loved jazz, the therapist should show up at her door with jazz already playing and say, "Come on, Kathy, let's go for a walk." "And that worked," Reinstein said. "That's all he needed to do."
She's candid, too, about the habits that get in the way of this kind of attentiveness: "Oftentimes I think, as PTs, we get in this habit of, okay, Mrs. Smith, you're coming in — alright, just, why don't you get on the bike — and then we walk away. But it's important to get to know your patient and get to know what makes them tick."
Core principles she teaches, framed for the rehab setting:
- Resist the righting reflex. Avoid simply telling a patient what to do, and instead listen with empathy rather than judgment.
- Ask open-ended questions. Replace yes-or-no prompts with questions like What change is most important to you?
- Affirm effort, not just outcomes. "You've shown persistence with your walking routine even on days you're not feeling your best."
- Practice reflective listening. Paraphrasing a patient's own words back to them demonstrates that they've been heard.
"We can't fix everyone," Reinstein acknowledged, "but we can help them get closer to where they want to be by empowering them."
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Character Strengths as a Coaching Tool
A second pillar of Reinstein's model comes from positive psychology: the VIA (Values in Action) inventory of 24 character strengths, which every person possesses in some combination.
Reinstein encourages clinicians to practice "strength spotting," naming a patient's strengths directly. "I see the perseverance you have by keeping up with your daily exercises," she offered as an example, "or despite everything you are experiencing, your humor remains in full force."
Reinstein shared her own results from the VIA assessment: love ranked as her top strength, which she said explains her emotional reaction to the photo of her mother and daughter. She credits two lower-ranked strengths, perseverance and love of learning, with getting her through her certification program during the hardest stretch of her family's crises, when she seriously considered dropping out. Strengths like hope, she noted, build naturally as patients rack up small wins.
The Three Modifiable Pillars: Nutrition, Exercise, and Sleep
The second half of Reinstein's presentation moved from communication strategy into the physiological substance of brain health, material Reinstein draws primarily from the RECODE protocol, developed by Dr. Dale Bredesen through Apollo Health.
Cognitive decline, she emphasized, begins decades before it's clinically diagnosed. "There's a substantial window of opportunity," she said, "to intervene on modifiable risk factors long before symptoms become clinically apparent."
Nutrition.
The RECODE approach favors leafy greens, cruciferous vegetables, wild fish, pasture-raised eggs, and healthy fats like avocado and nuts while minimizing sugar, refined carbs, seed oils, gluten, and ultra-processed foods. Vitamin D deficiency, common in northern climates like her own Buffalo, is strongly linked to cognitive decline but rarely discussed by neurologists in that context; her own mother's deficiency went unaddressed for years. The protocol also incorporates a minimum 12-hour overnight fast, extended further for patients carrying the APOE4 gene (a marker of elevated Alzheimer's risk), supporting autophagy, insulin sensitivity, and a mild ketosis that fuels the brain. Gut health rounds out the picture, since conditions like leaky gut and IBS drive the systemic inflammation that damages brain tissue.
Exercise.
Physical activity is, in Reinstein's words, "the single most powerful tool you have to optimize your brain function," and the mechanism she returns to repeatedly is the glymphatic system, the brain's own waste-clearance network. "It is like a washing of the brain," she explained, "getting rid of metabolic waste and toxic proteins... linked to neurodegenerative diseases." Exercise, along with deep sleep, is one of the primary triggers for this system.
Aerobic exercise specifically upregulates brain-derived neurotrophic factor, or BDNF. "BDNF is often referred to as the miracle-grow for the brain," Reinstein said. "This protein supports existing neurons and encourages the growth of new neurons, and exercise is the most powerful trigger for BDNF, and aerobic exercise increases it by up to 2 to 300% during and after exercise."
High-intensity interval training gets particular attention as a time-efficient option, creating what's known as hormesis, a controlled stress that strengthens the body. "It's that 'what doesn't kill you makes you stronger' concept," Reinstein said, and she was careful to lower the barrier to entry: "It doesn't have to be this daunting task. It's about getting the heart rate up for one to two minutes, and then back to baseline, and repeating this for 10-plus minutes."
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Perhaps the least intuitive finding she shared involves leg strength specifically: "In long-term studies, baseline leg strength predicted brain health years later, even after controlling for genetics and lifestyle." That means the squats and leg presses PTs already prescribe for mobility carry a brain-health dividend most clinicians, Reinstein included, never learned to name: "We're really good at working on lower extremity strength, but not equating it to improved cognitive performance. I mean, I know I definitely didn't."
Beyond strength and aerobic work, she also pointed to rebounding, tai chi, and dance, and was especially enthusiastic about dual-tasking, pairing a physical movement with a simultaneous cognitive challenge, like naming fruit in Spanish while pedaling a stationary bike. "There is significantly more cognitive benefit," she said, "when you're combining a physical and a cognitive exercise versus just doing a cognitive game or exercise alone in a silo."
Sleep.
Deep, non-REM sleep is where the glymphatic system does its most important work. During waking hours, neurons swell and pack tightly together, trapping waste proteins; during deep sleep, those neurons shrink by roughly 60%, opening wider channels for cerebrospinal fluid to flush the waste away.
She pointed to a specific, trackable target: roughly 90 minutes of deep sleep per night, nested inside a broader 7-to-9-hour window. The stakes are immediate: "Even one night of poor sleep increases amyloid plaques," she said, "because we are not activating that glymphatic system." And the scale of the problem is larger than most clinicians register: "Half the world's adult population falls short of the recommended 7 to 9 hours of nightly sleep, with profound consequences for brain health."
Her recommendations are concrete and low-cost: a consistent bed and wake time, a 12-hour overnight fast, screens off two hours before bed, a cool dark room, and morning sunlight to anchor the circadian rhythm. Reinstein was candid that this is a protocol she's adopted herself: "Since learning more about sleep, I've made tremendous change. I don't eat late at night. I have my wind-down routine, which always involves reading, and sleep has been drastically improved."
Case Studies: What This Looks Like in Practice
Reinstein grounded the model in three real patient profiles, tracked using the Montreal Cognitive Assessment (MoCA), a 30-point screening tool PTs and OTs can administer without additional certification:
- A 58-year-old sedentary executive with brain fog and poor sleep began graded aerobic and resistance training with sleep hygiene education; his MoCA rose from 25 to 27 over 12 weeks.
- A 67-year-old woman with mild cognitive impairment and reduced leg strength worked through progressive resistance and dual-task balance training; her MoCA rose from 21 to 24 over 16 weeks.
- A 72-year-old woman recovering from a fall, with significant social isolation, was referred into group-based strengthening and community re-engagement; her MoCA rose from 19 to 22 over six months, a jump Reinstein called considerable.
The Case for Rehab's Role
Reinstein closed with a challenge to her profession's own habits.
"I think it's imperative that we listen more with our patients," she said. "Often we're checking off the boxes, or typing things into the computer. But these people need help." Her conclusion: "PTs and OTs possess the clinical expertise to intervene at every stage of cognitive decline, from early prevention through advanced disease management... physical therapy and occupational therapy is not simply a supporting player. It's an essential one."
She left attendees with a story from one of her mother's own neurology appointments. After the visit, the physician's assistant handed her an updated prescription for her mother's medications. Reinstein asked a direct question: given the overwhelming evidence that exercise improves cognition in patients with dementia, why isn't there an automatic referral to physical therapy, the way there is for medication? "She paused," Reinstein recalled. "She looked at me for a second or two and said, 'I don't know.'"
"So there must be a change," Reinstein told the room, a call to action that starts, in her framework, with a single question asked a little more often: what is this patient's why? ◼
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