Orientation Cognitive Impairment After Stroke

What is Orientation? Orientation is something that we often take for granted – how do we know where we are? Or what month it is? We generally take cues from the environment to work these things out, for example if you were in hospital, you might look at all of the hospital beds and see the nurses around you and realise where you are. If you were on the second floor of a building, you might look out of the window to get an idea of what floor you are on. Our everyday routines help to orientate us to time (hour, day, week, month, even year). For example, if you work Monday – Friday then you know that when you aren’t at work, it’s a Saturday or Sunday. Imagine being unable to use these cues though – imagine not knowing where you are, what year it is, or even not really knowing who you are and who your family members are.

How to Spot Orientation Difficulties? Orientation to time questions What time of the day is it? What year are we in? How long have you spent in hospital? How long is it until lunch? When did you last go to the hospital gym?

How to Spot Orientation Difficulties? Orientation to place questions Where are you right now? Where do you live What city or town are we in? What is the nearest landmark to where you are now? What floor of the building are you on?

How to Spot Orientation Difficulties? Orientation to person questions What is your name? What is your date of birth and how old are you? Do you have any children? Are you married? Why are you in hospital?

Activity – Case Study An elderly lady arrives on the ward having had a stroke. She wakes up in a bed on a ward and is looking around frantically for something to help her to understand where she is. She calls for her husband who is always in the bed next to her. She is not used to being on her own and is terrified. What kind of things could you put in place to help this lady feel more secure and aware of her environment?

How Can You Help? Whiteboard Use the whiteboard by a patient’s bed not only to make notes for staff to read, but also to help orientate the patient. Questions such as “what floor are you on?” can be tricky if there are no obvious signs to inform patients exactly where they are. Make a note of their location on the whiteboard – “Mrs X, Ward 5, 2 nd Floor, St John’s hospital”. You can also use the whiteboard to write the date on, and the day’s activities for the patient, for example “10:00a.m. – Physiotherapy, 12:00p.m. – Lunch Time, 2:30p.m. – Daughter Visiting…”.

How Can You Help? Clocks and Calendars Always ensure that your patient has access to a clock and calendar, as most of us would be disorientated if we spent a long period of time in hospital without access to these things. A simple calendar printed off the computer is fine and can also be used as a diary for making a note of appointments, visiting hours and rehab time in the gym etc. Talking clocks and calendars are also beneficial for those with visual impairment.

How Can You Help? Scripts A script can be given to a patient which tells them information about themselves and about their situation. It can be tailored to the individual depending on the severity of their orientation difficulties. You might want to include information about the individual and their family, where they live, where they are currently, and why they are there. Including pictures is a nice way of making scripts more “user- friendly” and can be particularly helpful if a patient is having difficulties remembering the names/faces of friends and family.

Activity If you were in a strange environment, with people you didn't know and were feeling confused and disorientated - what information would you like to have at hand? Put together a script for yourself (as though you were a patient in an acute stroke ward), providing information about time, place and person. What else could you include in a script to provide comfort and a sense of security?

How Can You Help? You Always introduce yourself and your role to your patient even if they appear to recognise you. If you are going somewhere with your patient, for example to the gym, tell them where they are going and what they will be doing. Encourage patients to pay attention to their environment by pointing out colours of the walls and landmarks on the route, such as photographs or paintings on the wall. Take the same route each time so that they can have some familiarity with you and the environment in which you see them.

How Can You Help? Orientation Groups It can be helpful to offer some group activities which will help patients to gain an understanding of the time/date or their environment. The following ideas can be used either in groups or 1:1 with a patient: Reading the newspaper referring to the day and date Reading sections of the newspaper with current events and having a discussion about this Orientation quizzes Discovery trails to find out about the local environment

How Can You Help? Environment - Visual Landmark Orientation The environment is one of the most important factors in orientation and small changes can make a big difference to a patient who is disorientated: Ensure the environment is organised and that there are labels and landmarks to help clients orientate themselves. Try using something to mark out the bed or room of a patient with orientation difficulties. Labeling rooms such as the bathroom, toilet, kitchen and dining room can also aid reorientation to the environment.

How Can You Help? Environment – Familiarity Depending on your patient’s presentation and assessed difficulties, having familiar objects around them could help create a calm environment in which they can relate. The use of photographs and familiar objects or smells could help relax individual clients and can also help with memory. Talk to your patient and try to find out a little bit about their environment and routines at home. If you have a patient who feels that it is important to them to put their make up on when they wake up every morning, make sure they have the tools to do so.

Summary Orientation problems can affect different people in different ways, and can be a big contributor to challenging behaviour, mood difficulties and/or anxiety. Remember that an individual’s recall or recognition problems can have a big affect on orientation. Also consider whether your patient has any problems with insight, as meaning can have a significant affect on memory. Therefore if someone is lacking insight into the meaning of events/the environment, they may also struggle with their memory.