What 'Alert and Oriented' Means With Dementia

The term "alert and oriented" (AO) is a medical notation describing a person's level of consciousness and cognition (the ability to understand and learn through thought, experiences, and the senses). It provides a general first impression as to whether a person is cognitively impaired and able to make decisions for themselves. It is commonly used when dementia is suspected or known.

A person's alertness and orientation are assessed based on a series of questions. These fast and simple screening tools can be performed by a psychiatrist, psychologist, doctor nurse, social worker, or emergency medical technician (EMT).

What Alert and Oriented Means

Alertness and orientation help document where a person's consciousness and cognitive function are at that moment in time. It is not a diagnosis but rather an indication of how alert and oriented a person is based on their responses to several questions or physical prompts.

By definition:

• Alertness refers to a person's level of consciousness, ranging from aware to nonresponsive.
• Orientation refers to a person's awareness of person, place, time, and event/situation.

An AO mental assessment is useful in situations where an EMT or social worker is approaching an unknown individual and needs to quickly ascertain whether they have the capacity to make medical decisions for themselves.

The assessment also helps healthcare providers establish in what state of cognition a person with dementia is at that moment in time. (With certain types of dementia, like Alzheimer's disease, the AO can fluctuate and doesn't always reflect the person's overall status.)

The AO assessment is also used in legal situations to decide whether a person is alert and aware enough to show legal capacity to sign legal documents,

Alertness Levels

There are different systems used to determine a person's alertness when first approached by an EMT or healthcare provider. The aim of an alertness assessment is to establish how responsive a person is even before considering their orientation level.

The assessment is commonly performed using an AVPU scale. APVU is an anagram for four different levels of alertness, described as:

• Alertness: A person readily responds to questions and/or initiates conversation.
• Verbal: A person only responds when verbally prompted.
• Pain: A person does not respond to verbal stimuli but reacts when gently pinched or prodded.
• Unresponsive: A person does not respond to any verbal or physical stimuli.

Based on the APVU scale of 1 to 5, a person's alertness may be notated as:

1. Alert: The person's eyes are open and they are interactive and responsive.
2. Lethargic: They are drowsy and have low energy but can be aroused.
3. Obtunded: They are difficult to arouse.
4. Stuporous: They can only be around with vigorous stimulation.
5. Comatose: They are nonresponsive and have no interaction with their surroundings.

Orientation Levels

Orientation levels are determined based on open-ended questions that check a person's memory and thinking abilities. The questions check for awareness of four domains: person, place, time, and event.

Examples of questions commonly used include:

• Person: What is your name? Who is this person who brought you in today?
• Place: What city and state you live in? Where are you right now?
  
• Time: What day of the week is it? What year is it?
• Event: Do you know why you are here today? What happened to you?
  

Based on what the person may or may not be aware of, the EMT or healthcare provider will notate AO in one of four ways:

• AO x1 means that a person knows who they are but not where they are, what time it is, or what is happening to them.
• AO x2 means that a person knows who and where they are but not what time it is or what is happening to them.
• AO x3 means that a person is alert and oriented to person, place, and time but not what is happening to them.
• AO x 4 means that a person is fully alert and oriented to person, place, time, and event.

In legal practice, anything less than an AO x3 may limit a person's capacity to sign legal documents.

Uses With Dementia

Alertness and orientation are often assessed as part of a mental status exam (MSE) to evaluate cognitive functioning and to screen for dementia.

Dementia is the irreversible deterioration in two or more domains of cognitive function—memory, language skills, ability to focus and pay attention, ability to reason and solve problems, or visual perception—which affects a person's ability to perform everyday tasks.

There are several causes for dementia, the most common of which include:

• Alzheimer’s disease
• Vascular dementia caused by stroke
• Lewy body dementia
• Frontotemporal dementia
• Traumatic brain injury
• Huntington's disease
• Parkinson's dementia

An AO mental assessment is useful in people with dementia. Although it is not meant to diagnose dementia, it can provide insights into which stage of Alzheimer's a person is in.

With progressive forms of dementia, such as Alzheimer's, the loss of orientation usually follows the same pattern wherein event, time, and place are lost (in this order) before person.

As such, orientation to person is almost invariably an indication that an individual is in the most advanced stages of dementia.

AO Assessment With Delirium

Orientation can also be affected by delirium, a condition in which there is a sudden decline in cognitive ability.

Delirium is often caused by something temporary that is reversible. In such instances, an AO mental assessment can help determine how much intervention is needed if a person is in a state of incapacity.

Causes of delirium include:

• A fall or blow to the head
• Worsening chronic liver or kidney disease
• A severe urinary tract infection (UTI)
• Medication side effects
• Alcohol or drug withdrawal
• Severe electrolyte imbalances, such as low sodium or calcium
• Carbon dioxide poisoning
• Severe lack of sleep
• Severe high fever

If a person's orientation is rapidly impaired, this may be a sign that they are experiencing delirium.

Summary

Alertness and orientation (AO) are medical notations of a person's level of consciousness and cognition based on a series of questions or physical prompts. Alertness can be described on an AVPE scale of 1 to 5. Orientation can be described on an AO scale of 1 to 5.

Low orientation scores indicate a loss of cognition, such as can occur with Alzheimer's and other forms of dementia as well as delirium.