O-Log Syllabus

Mental confusion can be a significant barrier to independent living and to participation in rehabilitation. Measuring orientation is one way to evaluate confusion and has been helpful in documenting change over time. Orientation assessment is a component of all measures of mental status largely because it is quick to ascertain, can be scored objectively, and is generally agreed to be within the cognitive capacity of normal individuals. There are also individual scales to assess orientation, the most widely used being the Galveston Orientation and Amnesia Test (GOAT), particularly for those with TBI.

The GOAT was developed for use with people experiencing milder TBI, but the subsequent norming and extensive application over the years has included severely injured people. Unfortunately, there are several drawbacks to the GOAT. It is not easily applied to populations other than TBI because some of the questions relate directly to trauma. For those who are severely injured, and particularly those undergoing extended rehabilitation, some of the questions are confusing or unessential. For instance, it is not important to this population how the person was transported to the hospital and it is confusing to ask when the person was hospitalized since there may have been several hospital transfers prior to admission to the rehabilitation program. Some of the questions are also subjective, such as those involving the last recall of events prior to injury and the first recall of events after the trauma. Severely injured people (unlike those with milder injuries, with whom the scale was developed) often provide vague responses. When more detailed responses are provided, confabulation often becomes a factor. Finally, the scoring of the GOAT can be confusing. The final score is derived by subtracting error points from 100, although the scale items can add to 110. Scoring for individual items also varies, presumably based on the difficulty of the item. For instance, a subject may lose 30 points if grossly in error in stating the year, but only five points if the city is misstated. No objective data has been provided to justify such differential scoring, which can result in significant fluctuations in scores day to day if responses are inconsistent.

To address these difficulties the O-Log was developed. The O-Log focuses on orientation to place, time, and circumstance. It was decided not to include questions concerning personal background, such as a person's name and birth date, since such information does not adequately define cognitive impairment and the accuracy of the information may be questionable in some cases. Place is evaluated by asking for the name of the city and the hospital. The person is asked for the month, date, year, day of week and time of day to evaluate time. Circumstance refers to awareness that an event has taken place, such as a car crash or stroke or illness, and the impact of the event, such as a brain injury with motor or cognitive difficulties. The scale allows for spontaneous verbal responses, but responses based on cueing and non-verbal communication are possible.

The ten items of the O-Log are scored 0 to 3 depending on the response provided. A spontaneous correct response is awarded 3 points on any item. No item is weighted more than another. A score of 2 is assigned if the spontaneous response is lacking or incorrect, but a correct response is provided following a logical cue given by the examiner. For instance, if the person misstates the location, the examiner states, "This is a place where doctors and nurses work." If the person states it is January when it is March, the examiner states, "January was two months ago, so what month is it now." The content of the cue will vary depending on the error. A score of 1 is given if spontaneous and cued responses are lacking or incorrect, but a correct response is provided in a recognition format. For instance, the examiner would name three months, three years, three locations, etc. and ask the person to recognize the correct item. Zero points are assigned if the spontaneous, cued, and recognition formats do not generate a correct response. For fully oriented individuals the scale takes as little as three minutes to administer, whereas for those who are confused and require a recognition format for every question 10 to 15 minutes may be required. The scale can be administered at bedside or in any other setting.

Scores for each of the 10 items are summed to obtain a total score that ranges from 0 to 30. Specific domain scores can be calculated as follows: Place = City + Kind of Place + Name of Hospital; Time = Month + Date +Year + Day of Week + Clock Time; Situation = Etiology/Event + Pathology/Deficits.