People with brain damage, but also people with a form of dementia, can experience problems with orientation.
There are several types of problems with orientation that do not all have to occur in one person:

• orientation in time
  
• orientation in person
  
• orientation in place
  
• orientation in space
  
• orientation to objects.

Examples are:
In time: A person does not know what date it is, or may have difficulty estimating time, what day of the week it is or what season it is. Sometimes there is only a distorted sense of time. The internal clock is distorted. A person knows the concepts of 'next week' or 'in an hour' very well, but can no longer sense how long that will take.

This affects all sorts of aspects of life, such as preparing meals: is it safe to walk away from a pan on the stove? How do you estimate the travel time? What time do you meet and how much time do you need to get to the agreed location? Why does it take so long for the doctor to call back?
How long can I lie in bed to rest? Some people with a disturbed sense of time get out of bed after lying in bed for three minutes after an afternoon rest. The 'tired feeling' is always there and turned out not to be an indicator.
We have written a special page about the disorder in sense of time, which can sometimes manifest itself very subtly. (What time is it and what day?).

In person: The person no longer knows who he or she is, or does not know his or her age or date of birth. There is a loss of oneself that can give an unreal feeling. (Who am I?)

In place: The person no longer knows exactly how to get home. The person may have difficulty finding a place, the way or a route through a building. It is impossible for the person to find a starting point to find the way back.
We work out this problem on this page under the heading
navigation problems. (Where am I and how do I get there and there?)

In space: Spatial functions do not cover one functional domain. They include perception, attention, memory, actions and operations.
Spatial cognition includes:

1. Does the person realize where he or she is, and is there a correct orientation with respect to his or her own body parts?
   
2. Where does the person experience important objects in the environment, in relation to him or herself?
   
3. Where are these objects in relation to each other?
   
4. What does the person experience that he or she should do with these objects?
   
5. How should he or she do this?

Neglect (visual inattention) is also a form of a spatial orientation problem. A person perceives less or is less aware of what is happening on one side of the body or environment. There is nothing wrong with the eyes, but the brain does not process properly what is happening on one side of the body.

To objects: Being aware of objects and the properties of objects, for example visual agnosia. An example of this: a person sees an object lying on the table but does not know whether it is a remote control, a telephone or a kitchen utensil. Someone who has had a stroke does not realize what that black thing diagonally in front of and above his head is (the television). (What is that?)

Navigation problems

Research in 2017 showed that a third of people develop navigation problems after a stroke.
This can mean that someone has difficulty learning new routes after the brain injury, but also that someone can get lost in the neighborhood where they have lived for years, for example.
Another example is getting lost in a building such as a rehabilitation clinic or hospital.

Every year, tens of thousands of new people with brain injuries have to deal with these problems.
This navigation disorder severely limits people in their mobility.

Some people have had to give up their driving skills because of this problem. In the car you have to decide more quickly which direction to go, but traffic can be so complex that navigating is extra difficult.
Driving or walking through your own neighborhood does not always have to cause problems, but if someone has to go a little further away, they will have to prepare well how they will get there, and take more time to drive or walk from A to B. The chance of getting lost is then calculated into the travel time.
On the bike, someone can also encounter problems, for example, the road may be broken up, or there is a diversion due to an accident that has occurred.
When the temperature is high, these problems can also occur in people with brain damage who can normally find their way. In people with brain damage who can normally find their way, these problems can occur due to fatigue or overstimulation.

Wrong diagnosis

Neuropsychologist Michiel Claessen, who conducted the research into navigation problems after a mild stroke, stated: "Due to the failure to recognise navigation problems or an incorrect diagnosis, it takes much longer for people to actually receive the right treatment."

First of all, the brain injury may not have been diagnosed. This happens to many people, for example if the injury was not visible on a scan, or if a TIA turned out to be a cerebral infarction, or if someone wanted to see the symptoms at home after a fall and did not go to the emergency room. There are many examples.

Secondly, the problem of orientation problems is not always recognised properly. There are people with brain injury who were diagnosed with a panic disorder, but where the panic was only a consequence because the person could no longer see the routes properly and therefore lost her or his way.

Tests

Through collaboration between the UMC Utrecht and
Rehabilitation center De Hoogstraat, navigation problems can not only be recognized, but also addressed.
A questionnaire 'Wayfinding questionnaire' can be used to see if there are navigation problems and the 'Virtual Tübingen test' can be used to investigate the nature of these problems.
People may use two types of navigation strategies. Some use both:

• People who consider themselves as the center of the space as a navigation point and look at the surroundings from there, for example to take in recognizable buildings or striking places. From there they know whether to turn left or right (egocentric strategy).
  Example: "turn left at the bakery, straight ahead at the red tower and right at the football field, then I will end up at the market."
• People who use a kind of helicopter view as a navigation point. This means that they see a mental map of the environment in their mind (allocentric strategy).
  Example: "if I turn left now, I have to end up at the roundabout and then I have to go somewhere to the right".
  This is a more abstract way of navigating, but a more flexible way. Just think of the fact that if there is a roadwork, someone already knows that he has to go a little further to the left, and then a little back to the left to end up at the same point.

Which navigation strategy do you use?

Below we show the Virtual Tübingen test. The video has no spoken text, only music. You can turn off the music.
Please watch it. After the video we will ask a few questions.

If you have done this test with a neuropsychologist, you will be asked all kinds of questions about that route. Examples:
What did you see during the trip? Did you see a beer pub, a church or a bakery? Which turns were taken? The person being tested is shown various images of the route of the video and they have to be put in the correct order.
The answers to those questions and the order of the images then provide an image of the strategy used to process and remember routes.

Compensate

In an interview Michiel Claessen stated: "As soon as you know what a patient's strengths and weaknesses are, i.e. which strategy works best, you can consciously start practicing what still works well.
If egocentric navigation is still going quite well, you can start strengthening that strategy. First in a virtual environment and later just outside on the street. Moreover, people often find it very pleasant to know where the problems come from and to get tools to deal with them. They gain more self-confidence and dare to go out again."

The therapy therefore assumes that someone's skills are (relatively) well preserved and takes into account skills that have become weaker. The patient is taught to use the strong points more optimally.

The Brain

Simply put, a whole range of brain areas are involved in spatial orientation, including finding your way.
This also requires various functions such as seeing (visual function) what can be seen in the environment. Being able to store in the brain how a route is going and being able to remember it (working memory). Being able to plan a route also plays a role and if just one factor fails due to injury in that specific area, or in the extended neural network, then navigating can become more difficult.

The areas in the brain that are needed to find your way and the interconnections in a whole network of nerve pathways, cover almost half of the brain.

• The parietal lobe
  The parietal lobe also tells us, for example, which way is up; it is our spatial orientation.
  

• The hippocampus is involved in storing new memories and is known as the storage place for long-term memory.
  

• The fornix sends memory aids from the hippocampus to deeper brain areas. It is involved in learning processes, memory and spatial orientation.
  

• The frontal lobe is involved in planning.
  The cerebral cortex at the front of the frontal lobe (prefrontal cortex) is vital for working memory.
  

• The occipital lobe is involved in visual functions, among other things.

Tools

Navigation apps or bike computers may be able to help people with this problem (partly):

• Google maps
• Magic Earth
• HERE WeGo
• Sygic
• Waze
• TomTom GPS
• Bike computers with navigation, Garmin, MIO, Wahoo 

There are also wander detection tools, the so-called GPS trackers, that can let someone else know where you are.