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Adapting Care Across GEMS States: Diamond, Emerald, Ruby, Amber

This article helps you adjust your care approach as the person you support moves through different GEMS states. The GEMS model, developed by Teepa Snow, describes dementia as a dynamic condition where abilities and needs shift like ocean waves. You are not failing if your approach needs to change daily or even hourly. Here are concrete, step-by-step strategies for each state, with real words to say and practical tools to try.

Key points

  • GEMS states are dynamic; a person can shift between Diamond, Emerald, Ruby, and Amber within a day. Observe without judgment and adapt your approach.
  • Amber state is sensory-driven and often the hardest for caregivers. Use a low, slow voice, hand-under-hand touch, and environmental adjustments to calm the person.
  • In Diamond state, never argue. Validate their feelings and redirect to a safe activity. Use choice cards to give a sense of control.
  • For Ruby state, embrace repetition as comfort. Use a consistent routine and a repetition basket to meet their need for sameness.
  • For Emerald state, offer simple, engaging activities and reduce environmental distractions. Use visual timers for transitions.
  • Always use the Positive Physical Approach (PPA): approach from the front, pause, smile, offer your hand, and say their name before touching.

What Are GEMS States and Why Do They Matter?

The GEMS model compares dementia progression to gemstones, each with unique qualities. Diamond represents early stage, where the person sees themselves as fine and others as the problem. Emerald is a more flexible, on-the-go state where the person can still learn and adapt but may be easily distracted. Ruby is a state of repetition and routine, where comfort comes from sameness. Amber is a sensory-driven state where the person seeks or avoids sensations and can become overwhelmed, leading to behaviors that feel challenging to caregivers. This is not a linear path; a person may move between states within a day or week, depending on health, environment, and stress.

Why Amber Is Often the Hardest State for Caregivers

Teepa Snow notes that Amber is the state where caregivers often feel most impatient and rigid. When someone is in Amber, they are driven by sensory needs—they may be seeking intense input (like loud sounds or strong smells) or avoiding it (like bright lights or touch). This can trigger a caregiver's own sensory overload, making it hard to stay flexible. The key is to recognize that the person is not being difficult; their brain is locked in a sensory loop. Your job is to become a 'sapphire'—calm, centered, and able to adapt to whatever state they are in.

Diamond State: 'I Am Not the Problem, You Are'

In Diamond state, the person often refuses help because they do not see themselves as having dementia. They may become rigid about their preferences, insisting on things like a specific coffee cup or driving. This is not stubbornness; it is a protective response to losing control. Your approach must validate their perspective while gently redirecting. Avoid arguing or proving them wrong. Instead, use 'positive physical approach' (PPA): approach from the front, at eye level, with a warm smile, and use 'hand-under-hand' touch to offer connection without threat.

Emerald State: On the Go and Easily Distracted

Emerald is characterized by high energy and distractibility. The person may wander, start tasks but not finish them, or become anxious when idle. This state benefits from structured activities and environmental cues. Use short, simple instructions and break tasks into one-step directions. Offer choices that are safe and limited, like 'Do you want to fold towels or sort socks?' Keep the environment calm—reduce clutter and noise—to help them focus.

Ruby State: Routine and Repetition

Ruby state brings a need for routine and repetition. The person may ask the same question or do the same task over and over. This is comforting to them, not a memory failure. Your role is to join their rhythm, not stop it. Use music, familiar objects, and consistent daily schedules. When they repeat, respond with the same calm answer each time, or redirect to a related activity. Avoid showing frustration, as it can escalate anxiety.

Amber State: Sensory Seeking or Avoiding

Amber is the most challenging state for many caregivers because it is driven by sensory needs. The person may pace, shout, remove clothing, or touch everything. They are not being 'bad'; their brain is overwhelmed or understimulated. Your first step is to assess the sensory environment: Is it too loud? Too bright? Too cold? Then, offer calming sensory input: a weighted blanket, soft music, a warm drink, or gentle rocking. Use 'hand-under-hand' to provide safe touch. Speak slowly, with a low, calm voice. If they are seeking sensation, offer safe alternatives like a textured cloth or a fidget toy.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. 1. Identify the current GEMS state by observing behavior for 5-10 minutes. Diamond: rigid, blaming others. Emerald: busy, distractible. Ruby: repetitive, routine-bound. Amber: sensory-driven, overwhelmed. Write down what you see without judgment.

  2. 2. For Diamond state: Approach from the front, at eye level, with a warm smile. Use 'hand-under-hand' touch by placing your hand under theirs, palm up, and gently guiding. Say, 'I see you want your coffee now. Let me help you get it.' Avoid saying 'no' or correcting their memory.

  3. 3. For Emerald state: Offer a simple, engaging activity like folding laundry or sorting items by color. Use short phrases: 'Let's fold these towels. One at a time.' Keep the environment quiet—turn off the TV or radio. If they wander, redirect to a safe path with visual cues like a sign or a favorite photo.

  4. 4. For Ruby state: Establish a consistent daily routine with the same meal times, walks, and activities. When they repeat a question, answer with the same calm words each time: 'Dinner is at 6, just like always.' Use music from their youth to create a soothing backdrop. If they pace, join them for a short walk before redirecting to a seated activity.

  5. 5. For Amber state: First, check the environment: dim lights, reduce noise, lower the temperature if they are agitated. Offer a sensory tool: a weighted lap pad, a soft blanket, or a fidget cube. Speak slowly and in a low pitch: 'I am here. You are safe. Let's sit together.' Use 'hand-under-hand' to guide them to a comfortable chair.

  6. 6. For all states: Use the 'Positive Physical Approach' (PPA) every time: approach from the front, pause at arm's length, smile, offer your hand (palm up), and say their name before touching. This builds trust and reduces startle responses.

  7. 7. For Amber state specifically: If they are seeking sensation, offer safe alternatives like a bowl of rice to run hands through, a scented lotion to smell, or a soft brush to stroke their arm. If they are avoiding sensation, remove tags from clothing, use seamless socks, and offer a quiet, dark room.

  8. 8. For Diamond state: Validate their feelings without arguing. Say, 'I know you want to drive. That is important to you. Let's go for a walk instead.' Offer a parallel activity that mimics the desired action, like sitting in the driver's seat of a parked car with the engine off.

  9. 9. For Emerald state: Use visual timers or alarms to signal transitions. Say, 'In five minutes, we will have lunch.' Show a picture of the meal. Keep instructions to one step: 'Please sit down.' Wait 10 seconds for them to process before repeating.

  10. 10. For Ruby state: Create a 'repetition station'—a basket of familiar items like keys, coins, or fabric squares that they can sort or handle. This meets their need for repetition without frustrating you. Join them for a few minutes, then gently transition to another activity.

What not to do

  • Do not argue with a person in Diamond state. It backfires because their brain sees you as the enemy. Instead, validate their perspective and redirect to a safe activity.

  • Do not rush a person in Emerald state. They process slowly. Rushing causes anxiety and agitation. Instead, give extra time and use calm, simple language.

  • Do not change the routine for a person in Ruby state without warning. This triggers distress. Instead, prepare them with a visual schedule and give 10-minute warnings before changes.

  • Do not use loud voices or sudden movements with a person in Amber state. This overwhelms their sensory system and can lead to aggression. Instead, use a low, slow voice and approach from the front.

  • Do not take behaviors in Amber state personally. They are not about you. Instead, focus on the sensory need behind the behavior and adjust the environment.

  • Do not try to 'fix' the person's memory in any state. Correcting them increases shame and resistance. Instead, enter their reality and offer comfort.

Practical tools

  • Hand-Under-Hand Touch

    Place your hand under the person's hand, palm up, and gently guide or hold. This provides connection without threat. Use for all states, especially Amber and Diamond. Say, 'Let me help you with this.'

  • Sensory Calming Kit for Amber State

    A small bag with a weighted lap pad, a lavender-scented lotion, a soft brush, and a fidget cube. When the person is overwhelmed, offer one item at a time. Say, 'Here, feel this. It is soft.'

  • Visual Schedule for Ruby State

    A whiteboard with pictures of daily activities (e.g., breakfast, walk, lunch). Update it each morning. Point to it when the person asks 'What's next?' Say, 'Look, after lunch we have a walk.'

  • Choice Cards for Diamond State

    Two laminated cards with pictures of safe options (e.g., tea or water, walk or sit). Hold them up and say, 'Which one do you want?' This gives control without confrontation.

  • Music Playlist for Emerald State

    A playlist of songs from the person's young adult years (ages 18-25). Play it during transitions or when they seem restless. Music can ground them and reduce wandering.

  • Repetition Basket for Ruby State

    A basket with 10-15 safe, familiar objects: keys, coins, fabric squares, wooden spoons. Let the person sort or handle them. Join them for 5 minutes, then say, 'I will be back soon.'

Discuss with your clinician

If the person in Amber state shows sudden aggression or self-harm, discuss with a doctor whether a medication adjustment or a referral to a behavioral specialist is needed.

If the person in Diamond state refuses all care and becomes a safety risk (e.g., leaving the stove on), ask the clinician about a cognitive assessment and possible home safety evaluation.

If the person in Ruby state develops new repetitive movements (e.g., rocking, hand-wringing), discuss whether this could be a side effect of medication or a sign of pain.

If the person in Emerald state has frequent falls, ask the clinician about a physical therapy evaluation for balance and strength training.

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