Alert and Oriented x1, x2, x3, and x4 in Dementia

Orientation is often assessed as part of a mental status test to evaluate cognitive functioning and screen for dementia. It refers to a person's level of awareness of person, place, time, and situation.

When assessing a patient's orientation, the doctor asks standard questions that may seem like small talk, but are useful for testing recent and longer-term memories. Typical questions include:

• What is your name?
• Where are you?
• What is the date and time?
• What just happened to you?

Sometimes referred to as alert and oriented (AO or A&O) or awake, alert, and oriented (AAO), orientation is usually followed by the multiplication symbol (x) and a number, such as AOx3 or AAOx4.

The level—x1, x2, x3, or x4—is a way of expressing the extent of the patient's awareness. Here's what each measure of orientation means:

• x1: Oriented to Person. The patient knows his or her name and can recognize significant others.
• x2: Oriented to Person and Place. In addition to knowing his or her name, the patient knows where here or she is.
• x3: Oriented to Person, Place, and Time. In addition to knowing his or her name and location, the patient also knows the date, day of the week, and season.
• x4: Oriented to Person, Place, Time, and Situation. In addition to knowing his or her name, location, and time, the patient can explain the situation of why they are at the healthcare facility.

If a person can answer some information, but not all—for example, knows their name and the date, but can't say where there are—it would be notated as x3 minus place.

In some circumstances, healthcare providers may only ask about person, place, and time, so x3 is the highest level of orientation tested for. Others may also include situation for x4.

When treating patients with dementia, the healthcare providers notes should also include the specific questions asked and answers given.

Alzheimer's disease and other types of dementia can cause people to be disoriented about their surroundings and the setting. It's not uncommon for people with dementia to be especially disoriented about time. They may believe it's many years ago and that they are much younger than they are.

As Alzheimer's disease progresses, people also may become confused about where they are. For example, if asked the city and state in which they live, they may answer with the location of where they grew up, rather than where they've lived for the last 30 years.

Orientation to a person (or x1) is affected in the very late stages Alzheimer's disease where a person may not be able to remember his name or recognize himself in the mirror.

If someone with Alzheimer's disease becomes disoriented to location, they may wander around and attempt to leave, both due to their confusion about their place, as well as time. For example, a person may believe that she must leave for work and then get lost on her way to a job that she retired from many years ago.

Disorientation can present safety risks as well as distress and anxiety for people with dementia.

Interestingly, not all types of dementia impact orientation to the same extent as Alzheimer's disease.

A 2014 study published in the Journal of Alzheimer's Disease found that impairment in both orientation and memory was consistently present in patients with Alzheimer's disease, but those with frontotemporal dementia often maintained their orientation but their memory was impaired.

Disorientation is also common in Lewy body dementia and vascular dementia as they progress into their later stages. 

Orientation can also be affected by delirium, a sudden decline in someone's cognitive ability caused by a reversible condition such as a medication interaction or reaction or an infection.

If someone's orientation is suddenly poor, this is a sign that he may be experiencing delirium and warrants a medical exam and treatment.

Some research has found that reality orientation can be helpful in facilitating orientation and slowing cognitive loss in dementia. Reminding someone of the date, season, location and time of day should be done gently and with kindness.