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

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Orientation is something healthcare providers check when screening for dementia and evaluating cognitive abilities. It refers to a person's level of awareness of self, place, time, and situation.

Healthcare providers score a person's orientation on a scale of 1 to 4. The higher the number, the better oriented a person is considered. For example, if you are fully alert and oriented, x4 will be noted.

When testing a person's orientation, a doctor asks standard questions that may seem like small talk. But these questions are useful for testing recent and longer-term memories.

Typical questions include:

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

This article includes information about what different levels of orientation mean and how they relate to Alzheimer's disease, dementia, and delirium.

Orientation Levels in Dementia

Verywell / Laura Porter

Orientation Levels

In certain health assessments, orientation is sometimes referred to as "alert and oriented" (AO or A&O) or "awake, alert, and oriented" (AAO). It is usually followed by the multiplication symbol (x) and a number. For example, it may be written like "AOx3" or "AAOx4."

The level—x1, x2, x3, or x4—is a way of measuring the extent of a person's awareness.

Here's what the types of orientation mean:

  • Oriented to person: The person knows their name and usually can recognize significant others.
  • Oriented to place: The person knows where they are, such as the hospital, clinic, or town.
  • Oriented to time: The person knows the time of day, date, day of the week, and season.
  • Oriented to situation: They can explain why they are talking to the doctor.

Sometimes a person can answer some of this information, but not all. For example, they may know their name and the date but can't say where there are or why. In that case, it would be notated as x2.

In some circumstances, healthcare providers might only ask about person, place, and time. In that situation, x3 is the highest level of orientation tested. When a doctor includes questions about the situation, the highest level would then be x4.

In addition to the value (i.e., x3), a healthcare provider's notes should also include the specific questions asked and answers given.

Alzheimer's Disease

Alzheimer's disease is a type of dementia that can cause people to be disoriented.

Orientation may be affected in the following ways:

  • Time: It's not uncommon for people with dementia to be especially confused about time. They may believe it is many years ago or that they are much younger than they are.
  • Place: As Alzheimer's disease progresses, people may also become puzzled 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 in recent years.
  • Situation: If someone with Alzheimer's disease becomes disoriented to their situation, they may wander around and attempt to leave. This happens because of their confusion about what they are doing and why. For example, a person may believe that they must leave for work and then get lost on their way to a job that they retired from many years ago.
  • Person: In the late stages of Alzheimer's disease, a person may not remember their name or recognize themself in the mirror.

Disorientation can present safety risks and can lead to distress and anxiety. So it's important to have people around who understand the person's condition and who can take of them.

Other Types of Dementia

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

A 2012 study published in the Journal of Alzheimer's Disease found:

  • Alzheimer's disease consistently impaired both orientation and memory.
  • Those with frontotemporal dementia (also called Pick's disease) often did not have trouble with orientation but did have difficulty with their memory.

In later stages of Lewy body dementia and vascular dementia, disorientation is also common.


Orientation can also be affected by delirium, which is a sudden decline in someone's cognitive ability. Delirium is often caused by something temporary, like a reaction to a medication or an infection.

If a person's orientation becomes rapidly impaired, this may be a sign that they are experiencing delirium. If this happens, they should see a doctor right away.


Doctors use orientation tests to evaluate a person's cognitive abilities. Orientation is measured in relation to person, place, time, and situation. Values range from x1 to x4. The higher the score, the greater a person's awareness.

Low orientation scores may indicate a memory disorder, such as Alzheimer's, dementia, or delirium. If you or a loved one experiences sudden disorientation, you should seek medical care right away.

A Word From Verywell

If you are experiencing confusion or having difficulty with memory, it is important to talk to your doctor. Many things can cause a person to experience disorientation, including stress, depression, memory disorders, psychiatric conditions, medications, injuries, and health conditions.

It is normal to feel anxious or frustrated if you or a loved one are experiencing memory loss or confusion. Be gentle with yourself and your family and always be kind and gentle when reminding someone of the date, season, location, or time of day.

4 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Merck Manual Professional Version. How to assess mental status.

  2. Dumurgier J, Dartigues JF, Gabelle A, et al. Time orientation and 10 years risk of dementia in elderly adults: The three-city study. J Alzheimers Dis. 2016;53(4):1411-8. doi:10.3233/JAD-160295

  3. Yew B, Alladi S, Shailaja M, Hodges JR, Hornberger M. Lost and forgotten? Orientation versus memory in Alzheimer's disease and frontotemporal dementia. J Alzheimers Dis. 2013;33(2):473-81. doi:10.3233/JAD-2012-120769

  4. Meagher DJ. Delirium: optimising managementBMJ. 2001;322(7279):144–149. doi:10.1136/bmj.322.7279.144

By Esther Heerema, MSW
Esther Heerema, MSW, shares practical tips gained from working with hundreds of people whose lives are touched by Alzheimer's disease and other kinds of dementia.