A Little Orientation Can Go a Long Way
If you've ever talked with a medical provider, you may have experienced a line of questioning like this: "Hello, Ms. Jones. Can you tell me when your birthday is? And how old are you? Do you know what day it is? How about the year? What kind of a place is this? What is the name of this place? And how long have you been here?" Perhaps you are the provider asking these questions. And what are some common answers you may hear? "I don't have a watch or calendar." "I've never been good at keeping track of time." "Every day looks the same." Or even, "I wouldn't ever have known that."
Well, although some of these things statements can be true (it is difficult to identify the exact time without a watch, or the date without a calendar), a healthy brain is often able to use logic and inferences to generate a close answer, if not the correct one, or to use environmental cues to find the information. Disorientation and the inability to reorient to one's environment or self can be a key indicator that the brain is under some sort of medical duress and attention is needed. Chronic disorientation due to dementia or progressive illness can lead to agitation and frustration, as the inability to know where one is in space and time can cause high anxiety and can result in the primitive "fight, fight, flee" response, which may present as an adverse behavior.
In a healthy brain, periods of disorientation, such as not knowing that time it is or what day of the week it is, are often remedied by looking at a calendar, watch, or other visual (like our phones or computers). After we've reviewed the information once or twice, we often encode it and remember it as the day progresses, using the events of the day as a way to compare the passing of time over the day. In some cases, an individual uses recent events, such as holidays, birthdays, or even recalling a recent activity they completed and can reason through the passing of time by recounting or clarifying the order of events with those who were there. Many times people stay orientated in their day-to-day by writing information down, making lists, referencing notes, or discussing their day with others. This is all completely normal and is not an indicator of cognitive impairment.
Someone with persistent mild to moderate disorientation may be showing signs of an emerging cognitive or memory impairment. In these cases, if the disorientation is not linked to a treatable medical issue, such as dehydration, fever, or other acute illness (like a new stroke), it may be indicative of a decline that warrants further assessment. In cases where the medical ailment is treated and the disorientation persists, visual aids or other external cues, such as signs or planners, may be enough to support the individual through their day, but additional assessment should be explored. To maximize the use of these tools, the items must be placed in an easily accessible and visible location and regularly reviewed and updated. The support of another person may even be needed to facilitate consistent use until it becomes a habit.
An individual with moderate to moderately-severe disorientation may have a clear-cut cognitive impairment due to a related medical diagnosis, such as head injury, dementia, or stroke. Frequent and accurate reorientation in these cases can be used therapeutically to reduce stress, anxiety, confusion, repetitive questioning, and adverse behaviors. The availability of visible clocks, calendars, auditory stim (for the visually impaired or those unable to read), and verbal reminders of what the day is, what is coming up next, where they are, and where their loved ones are can promote awareness and engagement, which in turn improves feelings of safety and security, trust, and overall quality of life. Discussion of time (including holidays and weather-related topics), place, and personal concepts can promote wellness, enhance language output, and help the individual feel more in control, all of which can slow and reduce the progression or exacerbation of their deficits.
Individuals who have more severe cognitive impairments can often be overlooked when it comes to reorientation techniques. These individuals are often in an advanced stage of dementia and are highly dependent on others. They may not be living in their own home, may have a roommate they do not know, or have new or frequently changing caregivers. As their cognitive functions deteriorate, they may find themselves unable to articulate their stress or anxiety related to their new routines, their environment, or the people around them. An individual with this level of disorientation needs a gentle and consistent approach, someone to take the time to provide personalized care and attention and to help the individual feel calm and safe in their environment. If the individual is living in a highly supported setting, this may look like a large visual calendar that is updated daily, a caregiver reading or repeating this information and talking about the weather or an upcoming event or holiday, or even just asking the individual if they enjoy this time of year. In a setting where the individual is mobile, either by wheelchair or ambulation, walking with them around their environment and locating or pointing out visual pieces of reference, maybe their name on the door, or counting the numbers on the doors to find their own, can be useful. If repetitive questioning occurs regarding orientation, remember it likely is stemming from a place of anxiety, distress, fear, or frustration, so a caregiver or communicating partner should take the time to seek out the root of the repetitive questioning while providing gentle reorientation and comfort.
The next time you overhear a medical professional asking these questions, or you find yourself answering them, remember that orientation can be a key way to identify illness and screen for cognitive decline. For individuals with an identified cognitive impairment, orientation can promote engagement, control, safety, and feelings of comfort, all of which help to reduce the rate of decline and promote increased quality of life. And, if you find yourself writing the wrong date all day, or not knowing what time it is, know that as long as you are recognizing the error and finding ways to remedy it, you're brain is doing its job, and the next day will likely be better.