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.

When testing a person's orientation, a doctor asks standard questions that may seem like small talk. But these questions are useful for seeing how well a person can recall 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 each level of orientation means:

  • x1: Oriented to person. The person knows their name and can recognize significant others.
  • x2: Oriented to person and place. In addition to knowing their name, the person knows where they are.
  • x3: Oriented to person, place, and time. In addition to knowing their name and location, the person also knows the date, day of the week, and season.
  • x4: Oriented to person, place, time, and situation. In addition to knowing their name, location, and time, they can explain why they are at the healthcare facility.

Sometimes a person can answer some information, but not all. For example, they may know their name and the date but can't say where there are. In that case, it would be notated as x3 minus place.

In some circumstances, healthcare providers might only ask about person, place, and time. In that situation, x3 is the highest level of orientation tested. However, when a doctor includes 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. With Alzheimer's, 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 for the past 30 years.
  • Location: If someone with Alzheimer's disease becomes disoriented to location, they may wander around and attempt to leave. This happens because of their confusion about their place and time. 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 can support 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 is suddenly poor, 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 having difficulty with memory or confusion, it is important to talk to your doctor. Many things can cause a person to experience disorientation, including stress, depression, memory disorders, 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 use care when reminding someone of the date, season, location, or time of day.

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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.
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