What Does “Alert and Oriented” Mean?

A nurse with a mask.

The phrase “alert and oriented” is one you may have heard in a healthcare setting. It refers to a description of one’s level of awareness of reality at that moment. Orientation can be described as being aware of person, place, time, and sometimes situation. Assessing one’s orientation helps in the evaluation of mental status. It could help in the diagnosis of dementia or other conditions, as well as generally assessing one’s cognition. 

Having problems with awareness can lead to disorientation, an altered mental state. This can be caused by numerous factors. Usually, the disorientation will affect one’s grasp of the situation first, then time, then place, and finally of the person. Being disoriented can also happen alongside some other common symptoms like:

  • Confusion
  • Delirium
  • Disrupted attention
  • Delusions
  • Believing false things
  • Agitation, aggressiveness, or restlessness
  • Hallucinations
  • Wandering

Perhaps your loved one is showing some of the symptoms listed above. If that is the case, we strongly recommend that they visit their doctor, where they will receive a mental status check. This status check is a common procedure which medical professionals conduct. Assessing one’s awareness should be performed after a variety of circumstances have occurred. Some common circumstances would be:

  • When patient intakes are performed
  • After a procedure in which anesthesia or painkillers were used
  • To assess the progression of a disease or urinary tract infection
  • To check a reaction to a medication
  • After an accident, shock, or major trauma 

Assessment of Levels of Orientation

At times a patient might be perfectly capable of carrying on a normal conversation, but then not know their name. This is why checking one’s orientation is so important. Carrying out a mental status exam is as simple as the doctor asking a few questions. These questions may come across as small talk, but the simple answers they coax out are quite informative as to one’s cognitive abilities. Some assessment questions a doctor may ask could be:

  • What is your name?
  • Where are you?
  • What is the date?
  • What day of the week is it?
  • Why do you think you’re here?
  • What just happened to you?

The patient’s level of consciousness is then characterized in a mnemonic format. The acronyms AO or A&O (alert and oriented) are commonly used, while the abbreviation AAO (awake, alert, and oriented) can also be used. The acronym is followed by a multiplication symbol (x), then a number. Some examples would be AOx2 or AAOx3.

The level of awareness is expressed by x1, x2, x3, or x4. The number describes how aware the patient is, x4 being the most aware of reality. Here are the varying levels or orientation:

  • Oriented to Person (x1): This person knows his or her name and can also recognize their significant others. The common questions to determine this would be, “Who are you?” and “What is your name?”
  • Oriented to Person and Place (x2): This person knows his or her name as well as where he or she is.  The common question to determine this would be, “Where are you?”
  • Oriented to Person, Place, and Time (x3): This person knows his or her name, location, as well as the day of the week, date, and season of the year. The common question would be, “What is today’s date?”
  • Oriented to Person, Place, Time, and Situation (x4): This person knows his or her name, location, and time, as well as why they are currently being treated. The common question would be, “Do you know what is happening right now?”

Asking these questions when a patient is first being seen by the doctor can be compared against any following visits. Any change in the conscious state may help bring to light any underlying issues the patient may be having. Sometimes a patient can answer parts of the questions, but not all. They may know their name and what day it is, but don’t know exactly where they are. In this case, they would be considered AOx3 minus place.

It is also helpful to know that some medical settings only assess the patient’s knowledge of person, place, and time. Therefore AOx3 would be the highest orientation level instead of AOx4. In some settings like within emergency response teams, the letters can be documented as conscious, alert, & oriented (CAO) instead of awake, alert, and oriented (AAO). For example, it would read COAx4 instead of AAOx4. Often the emergency teams ask the patient questions before doing a physical examination in case there is a serious injury that is indicated from how they answer. 

Another completely different system of measuring the level of consciousness is the AVPU scale. This scale is typically used within first aid and emergencies. The acronym AVPU stands for Alert, Voice (responds to), Pain (responds to), and Unresponsive. Healthcare providers will determine what level the patient embodies checking in order from the best-case scenario (A) to worst (U). This is done to avoid any further tests on someone who is not conscious. When the determination is that the patient is alert, they can then pick up on the orientation scale and assess if they are x1, x2, x3, or x4. Still another way to assess the level of consciousness is through the Glasgow Coma Scale

It’s important to be alert and oriented, especially in emergency situations.

Ailments Which Cause Disorientation

It is still unknown which part of the brain affects one’s awareness of reality, but lesions on the brain stem and hemispheres have been said to cause disorientation. This suggests that these parts of the brain work together to maintain awareness. There is an array of physical ailments or situations that cause disorientation. Some of them include:

  • Vitamin deficiency
  • Stroke
  • Amnesia
  • Concussion
  • Carbon monoxide poisoning
  • Dehydration
  • Brain tumor or hematoma
  • Fever
  • Drug overdoses
  • Epilepsy
  • Hypothyroidism or hyperthyroidism
  • Hypoxia
  • Electrolyte abnormalities
  • Renal failure
  • Mitochondrial disease
  • Orthostatic hypotension
  • An emergency which causes distress
  • Triggering of mental disorders

Though all of these can cause disorientation, we will go over some of the most common causes of this cognitive disability in the elderly. These include Alzheimer’s disease, other forms of dementia, and delirium. 

Alzheimer’s Disease and Other Types of Dementia

Alzheimer’s and other types of dementia develop slowly. The symptoms are consistent and progressive, disorientation, and short-term memory loss being some early signs. Alzheimer’s disease is a form of dementia that affects memory, behavior, and thinking. People with the disease commonly become disoriented about where they are, as well as time. They often think they are living in a much younger version of their lives from long ago. It is common for them to be confused about where they are as the disease progresses out of the early stages. They may believe they are living in a completely different area, perhaps even one in which they lived as a child. The late stages of Alzheimer’s could disorient the person to an AOx1 level where they do not even know their name. 

Someone unaware of their location and time can often start to wander and may even try to leave. For example, he or she may think they are in their childhood home, and that they must leave to go to school. It is common for Alzheimer’s sufferers to wander, getting confused, anxious, and lost. In this situation, being in a memory care facility is the best option to ensure your loved one’s safety. 

Other types of dementia do not all have the same orientation issues like Alzheimer’s disease. Alzheimer’s’ patients experience issues with awareness and memory, whereas with frontotemporal dementia, memory is more often impacted. However, disorientation does often occur in other forms of dementia like Lewy body dementia and vascular dementia, especially in the later stages. 

Family members’ interaction with the individual is critical for detecting dementia. Making sure they are aware of reality by asking them simple questions like where they are can help with early detection. These are questions you wouldn’t usually think to ask, but being aware of early warning signs can help get your loved one treatment sooner rather than later. When taking your loved one for check-ups with their doctor, he or she must note what questions they have asked, and what answers were given. The following visits may have different answers, indicating a progression of the disease. 

Delirium

Delirium is a sudden worsening or change in one’s mental state. He or she may experience reduced thinking capacity, short attention span, unusual speech, and hallucinations. People who are affected may become disoriented. Delirium may be caused by many things including a certain type of medication, an infection, a change of location, or a trauma. Someone can experience this mental state change after undergoing surgery or being in an emergency room. 

There are three types of delirium, including hyperactive, hypoactive, and mixed. Someone experiencing hyperactive delirium may be behaving with agitation and having hallucinations. Hypoactive delirium is characterized by drowsiness and becoming withdrawn. Mixed delirium may have symptoms of both of these types. 

Those experiencing this state change can see it go away within days or weeks. Not all cases are the same, and your loved one’s character may fluctuate. The disorientation may only last for a short period. However, if your loved one is acting disoriented without any warning signs from a known disease or other explanation, it is recommended that you take them to see a doctor immediately. Continue to assess their awareness and orientation while he or she is delirious to see the progression.

Ability to Participate in Legal Proceedings

Now we know a bit about those experiencing varying levels of consciousness. It can be easy to imagine that someone who doesn’t know their name simply cannot make decisions for themselves. But at what point are they considered unfit to determine their legal matters? 

Often someone with Alzheimer’s or another ailment which affects one’s consciousness level will need to sign a power of attorney for someone to handle their affairs for them. This should be done at a time they are deemed oriented enough to understand what is going on. Otherwise, someone with a low level of awareness may be coaxed into a decision that could be bad for them. It is also important that someone who is not properly oriented is not allowed to make any critical decisions for him or herself. Therefore their level of consciousness must be known by any attorney or judge involved in the process. 

As stated before, A&Ox4 is the highest level of awareness, indicating that someone is completely normal and based in reality. Comparatively, those with a level of A&Ox2 do not know what time it is or what is happening. Someone at this capacity probably will not carefully read and attempt to understand legal documents presented to them. Keep in mind, however, that the level can change from day-to-day. He or she may be an A&Ox2 one day, and then at an A&Ox4 the next. During the day they can also fluctuate from one end of the spectrum to the other. It is important to monitor your loved one’s awareness throughout the day to predict when he or she will be most alert.

Knowing the patterns of your loved one’s consciousness level can help know when it is a good time to put legal documents in front of them. The window of time when someone has the mental capacity to sign important legal documents is called a lucid interval. Even those with Alzheimer’s or other forms of dementia may experience lucid intervals. The interval can last anywhere from minutes to hours. Sometimes lawyers will meet with their disoriented clients a few times just to ensure their awareness of what they are doing, and that they understand the process. 

The attorney involved must be questioning whether someone might challenge the legal proceeding taking place. If, for example, the disoriented person is trying to leave all the ownership of his or her estate to one child, and not another, this may raise a suspicion of the attorney. The attorney must be sure to assess the person’s orientation level to be sure that he or she is deciding with awareness. 

The determination of whether or not the client is lucid enough is a mix of medical, legal, and psychological judgments. This is often done by the attorney and based on conversations with the client, their family members, social workers, and even medical advisors. Sometimes a judge will be involved in the process of guardianship decisions are being discussed. Medical doctors or doctors of psychiatry are not able to make the judgment of whether or not the disoriented person is lucid enough to make a legal decision. They do, however, give their evaluation of the patient to the attorney who will use it to make the determination. If the attorney still cannot decide based on all the evidence, a neuropsychologist may be sought out to evaluate whether the person is aware enough to understand the situation. 

Creating a calm environment is key when someone is not alert and oriented.

How to Interact with Someone Who is Not Alert and Oriented

Dealing with a loved one who is experiencing disorientation is difficult. The person does not seem to be who you used to know them to be, which can be sad, frustrating, and confusing. However, despite how this change may make you feel, it is important to still treat your loved one with gentleness and kindness. Reminding them of the date, season, time of day, and location can help jog their memory. There are also a few other things you can do to help:

  • Be aware of their habits, medical history, medications, and symptoms. By knowing these things and presenting any of the information can help the doctor determine a diagnosis. 
  • Create a calm environment. You can do this by making their surroundings familiar to them. Surround them with their favorite objects to soothe them. If their location has to change, bring along these objects to give them some sense of familiarity. 
  • Surround them with familiar people, including yourself. People that bring your loved one comfort will help calm and relax them, which can help ease disorientation. It is also helpful to be around when your loved one is examined by the doctor. Having a familiar face can help the doctor assess what their normal behavior is like. 

Person, Place, Time, and Situation

If your loved one is showing signs of disorientation and has yet to seek medical help, encourage them to visit their doctor. If he or she is so disoriented that they seem like a danger to themselves or others, call 911. We here at CareAsOne think that checking in on your loved one is not only good for their mental health but assessing their consciousness level can help you catch some diseases early. 

In this article, you have learned that determining someone’s awareness level is as easy as asking questions regarding their person, place, time, and situation. Asking these simple questions regularly will help you easily zone in on cognitive impairment. And keep at it. We commend you for your care and dedication to your loved one’s health and wish you all the best. 

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