What Does Oriented x1, x2, x3 and x4 Mean in Dementia?

Orientation is a term that encompasses a person's awareness of herself, those around her, her location and the date and time. Oriented x1, x2, x3 or x4 is a way of expressing the extent of her awareness. Orientation is often assessed as part of a mental status test to evaluate cognitive functioning and screen for dementia.

You may hear a physician state, "She is alert and oriented times three." That means that she is awake and responsive, and oriented to person, place and time.

• Oriented x 1 = awareness of person
  • Sometimes, a person is oriented only to himself. That means he knows who he is but can't recall or recognize anyone else—for example, who they are or what their names are.
• Oriented x 2 = knowledge of place
  • Location may include general awareness of where the person is, such as in a hospital, the room number at a nursing home, or city and state.
• Oriented x 3 = knowledge of time/date
  • Time may include an awareness of date, time of day and season.
• Oriented x 4 = knowledge of event
  • Event awareness may include knowledge of what just happened or why he's at the hospital.

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 especially be 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 may also 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.

Finally, orientation to a person is affected by Alzheimer's disease in the very late stages where a person may not be able to remember his name or recognize himself in the mirror.

If someone becomes disoriented to location, they may wander around and attempt to leave, both due to their confusion about 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. Thus, 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 study was published in the Journal of Alzheimer's Disease about frontotemporal dementia which demonstrated that an impairment in both orientation and memory was found consistently in Alzheimer's, while people 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 is assessed in both formal evaluations and informal conversations. Several mental status exams include questions about the date, the season of the year, and their location (hospital, home, city, county).

Orientation can also be assessed through informal conversation by asking the person a few questions and listening to their responses.

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.