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Using the GEMS Workbook and Toolbook to Understand Brain States in Dementia Care

The GEMS workbook and toolbook are practical, hands-on resources created by Teepa Snow’s Positive Approach to Care. They help you move beyond a generic dementia label and instead identify where your loved one’s brain is functioning right now—using the gemstone analogy (Sapphire, Diamond, Emerald, Amethyst, Ruby, Pearl). This isn’t about labeling or limiting someone; it’s about seeing their retained strengths and adjusting your approach so you both feel more successful. There are concrete tools, observation guides, and step-by-step strategies inside these books that you can start using today.

Key points

  • The GEMS workbook and toolbook help you move from a generic dementia label to a specific, observable brain state that changes daily.
  • The six gem states (Sapphire, Diamond, Emerald, Amethyst, Ruby, Pearl) give you a clear framework for what to expect and what to try.
  • Use the observation checklist from the toolbook to assess current abilities before choosing a care approach.
  • The pocket GEMS card is a quick reference you can use in the moment, especially during stressful situations.
  • Combine the workbook with a life history tool to personalize care—knowing the ‘who’ and the ‘how’ together is powerful.
  • Reassess regularly and share observations with the care team to ensure consistent, person-centered support.

What Are the GEMS Workbook and Toolbook?

The GEMS workbook and toolbook are companion resources developed by Teepa Snow’s Positive Approach to Care. They are designed to help you—whether you’re a family caregiver, a home health aide, a hospice worker, or a trainer—understand and respond to the changing abilities of a person living with dementia. Instead of thinking in vague stages, the GEMS model uses six gemstone states: Sapphire (optimal brain function), Diamond (early changes, still high functioning), Emerald (moderate changes, needs cues), Amethyst (significant changes, needs hands-on help), Ruby (very advanced changes, needs total care), and Pearl (end of life, sensory-focused). The workbook breaks down each gem state into detailed descriptions of what a person can still do, what they struggle with, and what specific verbal, visual, and touch cues work best. The toolbook provides ready-to-use cards, checklists, and observation forms so you can assess where someone is today—because brain states can shift from morning to evening.

Why This Approach Helps Reduce Frustration and Burnout

Many caregivers feel overwhelmed because they expect the person to remember instructions or follow a routine that no longer fits their brain state. The GEMS workbook helps you shift from frustration to curiosity. Instead of thinking ‘Why won’t she eat?’ you learn to ask ‘What gem state is she in right now, and what does that mean for how I offer food?’ This shift reduces emotional exhaustion because you stop fighting against the disease. The workbook also includes guidance on how to build rapport, how to use environmental modifications, and how to involve the person in meaningful activities that match their current abilities. When you have a clear framework, you feel more competent and less isolated—which directly lowers the risk of caregiver burnout.

How the Workbook and Toolbook Are Structured

The workbook is divided into sections for each gem state. For each state, you’ll find a list of verbal abilities (what words they can understand and use), touch-and-feel abilities (how they respond to sensory input), and retained skills (things they can still do with the right support). There are also ‘strengths and challenges’ tables that help you plan care. The toolbook includes a pocket-sized GEMS card that you can carry with you. This card gives you a quick reference for what to expect and what to try. The resources are designed for use in home health, hospice, private duty, and staffing settings. Trainers can use them to teach staff how to observe and adapt in real time. The workbook also includes space for you to write down your own observations, making it a living document that grows with your caregiving journey.

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

Step-by-step

  1. Get the GEMS workbook and toolbook from the Positive Approach to Care website; read the introduction to understand that brain states are fluid snapshots of current function, not permanent labels.

  2. Use the observation checklist in the toolbook to identify the current gem state: note verbal abilities (e.g., follow a two-step instruction, find words), motor skills (e.g., use a fork, walk unaided), and sensory responses (e.g., reaction to noise or touch).

  3. Match communication to the state: for Emerald, use short sentences, one instruction at a time, and visual cues; for Ruby, use gentle touch, slow movements, and single words like 'sit' or 'drink.'

  4. Plan daily activities using the strengths and challenges table for the current gem state—word games for Diamond, repetitive soothing tasks like folding towels for Amethyst.

  5. Reassess regularly with the tracking form and share observations with the care team so everyone works from the same picture.

  6. Keep the pocket card handy for stressful moments; when agitation spikes, identify the likely state and try the recommended calming approach (e.g., slow rocking and soft voice for Ruby).

  7. Pair the GEMS framework with a life history tool (e.g., a 'Gather Details, Routine, Reminisce, Assess, Calm, Excite' form) to combine the 'how' of current abilities with the 'who' the person has always been.

What not to do

  • Do not treat the gem state as a permanent label—reassess daily; assigning a fixed state leads to missed engagement opportunities.

  • Do not skip observation and jump straight to techniques; always start by watching what the person can still do.

  • Do not share the GEMS card with the person in a clinical or labeling way—use gem names as private shorthand and aloud say things like 'Let's try a slower pace today.'

  • Do not overlook sensory and environmental tips; for a Pearl-state person, gentle touch, soft lighting, and familiar sounds are essential to prevent agitation or withdrawal.

  • Do not use the workbook as a substitute for medical advice—consult a clinician if you notice sudden changes in function.

  • Do not argue with or correct the person's version of reality, especially at Amethyst, Ruby, or Pearl states where confusion is expected.

Practical tools

  • GEMS Pocket Card

    A laminated card listing all six gem states with cues on verbal ability, motor skills, and caregiver approach. Keep it on hand for quick reference—e.g., for Amethyst, it reminds you to use one-step instructions and offer a guiding hand.

  • Observation Checklist

    A printable form for assessing verbal communication (yes/no responses, two-step commands), motor skills (spoon use, walking), and sensory responses (noise tolerance, touch enjoyment). Fill out weekly or after significant changes and share with the care team.

  • Strengths and Challenges Table

    Found in the workbook for each gem state, pairing retained strengths with current challenges. Use it to plan the day—e.g., Diamond's ability to read a short story paired with challenge of complex tasks suggests offering reading but skipping meal planning.

  • Environmental Modification Tips

    State-specific suggestions: reduce clutter and label drawers for Emerald; use contrast (dark plate on light table) and remove mirrors for Ruby. Write relevant tips on sticky notes and place them in care rooms to let the environment support soothing.

Discuss with your clinician

If you notice a sudden drop in gem state (e.g., from Diamond to Ruby in a day), ask the doctor: ‘Could this be a urinary tract infection, medication side effect, or another medical issue?’

Before using any weighted utensils or adaptive equipment mentioned in the workbook’s environmental tips, ask an occupational therapist: ‘What specific tools would match my loved one’s current gem state and physical abilities?’

If the person is in the Pearl state and you are considering changes to pain management or feeding routines, ask the hospice or palliative care team: ‘How can we use the GEMS sensory guidelines to improve comfort without overmedicating?’

If you are a trainer using the workbook with staff, ask your facility’s medical director: ‘Are there any state regulations or care plan requirements we need to align with when using the GEMS model?’

If the person with dementia is also on medications for other conditions, ask the pharmacist: ‘Could any of these drugs be affecting their current gem state, especially alertness or motor control?’

Related guides

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