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Ruby vs. Pearl GEMS States: What Changes and What to Do

In the middle to late stages of dementia, the Ruby and Pearl GEMS states represent two very different ways a person experiences the world. Ruby is strong, active, and internally focused—wanting to do repetitive tasks alone, often resisting help. Pearl is withdrawn, fragile, and reflex-driven—needing gentle, slow, and sensory-based care. Understanding which state your loved one is in at any given moment helps you respond with the right approach, reducing frustration and keeping both of you safer. This article gives you concrete steps, phrases, and tools to adapt your care in real time.

Key points

  • Ruby = strong, active, internally focused, resists help. Pearl = still, reflex-driven, sensory, needs slow approach.
  • Join Ruby’s activity without talking; use hand-under-hand for care. Use single sensory cues and slow approach for Pearl.
  • State can shift within a day—check every 2–3 hours and adjust your approach.
  • Never force care on a Ruby who is resisting; back off and try again later.
  • Pearl is not 'not there'—they are processing slowly. Speak as if they understand.
  • Your own state matters: calm yourself before approaching. A rushed caregiver makes both states worse.

What Is the Ruby GEMS State?

When someone is in a Ruby state, they are strong but have lost many of their skills. They may want to rake leaves, walk endlessly, rock in a chair, or sing to themselves—but they do not want to be interrupted or helped. As Teepa Snow explains, a person in Ruby is 'very strong but I don't have a lot of skills' and can 'make big mistakes and not realize I’ve made a mistake' (source 4). This state is internally focused: the person is absorbed in their own sensations and actions, not in connecting with you. They may resist care because they don't understand why they need it, and they may become agitated if you try to redirect them. Ruby is common in middle-stage dementia when the person still has physical energy but their brain can no longer organize tasks or recognize danger.

What Is the Pearl GEMS State?

Pearl is a state where the person is living almost entirely in the moment, driven by reflexes and sensations rather than thought or intention. Teepa Snow describes Pearl as being 'controlled by reflexes' and notes that 'not much happening' on the surface, but 'there is a lot going on' inside (source 3). In Pearl, the person may be very still, not speaking, not making eye contact, and not responding to your words. They may startle easily or have involuntary movements. This state is common in late-stage dementia, but it can also appear temporarily in earlier stages when the person is exhausted, overwhelmed, or ill. The key difference from Ruby is that Pearl is not resisting—they are simply not able to engage. Care becomes about gentle sensory input and protecting their comfort, not about managing behavior.

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

Step-by-step

  1. 1. Observe the person’s energy and focus for 30 seconds before acting. If they are moving with purpose (even if repetitive) and seem absorbed in an activity, they are likely Ruby. If they are still, quiet, or staring, they are likely Pearl.

  2. 2. For Ruby: Join their activity without talking. If they are raking, pick up a second rake and rake nearby. If they are walking, walk beside them at their pace. Do not try to start a conversation—Ruby is internally focused and words can feel like an interruption.

  3. 3. For Ruby: Use the 'hand-under-hand' technique to offer help. Place your hand palm-up under theirs and gently guide their hand to a task (like holding a cup or a washcloth). This gives them control and feels less invasive than grabbing their hand.

  4. 4. For Ruby: If they need care (bathing, changing clothes), wait for a natural pause in their activity. Then say, 'I need your help for a minute—can you hold this for me?' and hand them a washcloth or a towel. This frames care as a shared task, not something done to them.

  5. 5. For Pearl: Approach slowly from the front, at eye level, and wait for them to notice you. Do not touch them without warning. Say their name softly, then say, 'I’m going to put my hand on your arm now,' and pause before doing it.

  6. 6. For Pearl: Use single sensory cues—a warm washcloth on their hand, a familiar song humming softly, a gentle rocking motion. Do not try to get them to 'do' anything. The goal is comfort and connection, not task completion.

  7. 7. For Pearl: If they startle or stiffen, stop and step back. Give them 10–15 seconds to settle. Then try again with a slower approach or a different sensory cue (like a different temperature or texture).

  8. 8. Watch for state shifts during the day. A person may start the day in Ruby (wanting to walk) and shift to Pearl after lunch (becoming still and quiet). Adjust your care approach each time you notice a change—don’t assume one state lasts all day.

  9. 9. For both states: Check your own state first. If you are rushed, frustrated, or tired, you may be in a 'Sapphire' or 'Amber' state yourself. Take three deep breaths before approaching. Your calm presence is the most powerful tool you have.

What not to do

  • Do not try to 'correct' a Ruby person's repetitive behavior (like raking the same spot for an hour). This will likely cause frustration or agitation. Instead, join them or redirect with a similar motion (e.g., folding towels instead of raking).

  • Do not use complex language or ask multiple questions with a Pearl person. 'Do you want water or juice?' is too much. Instead, offer one choice: 'Here is some water' and hold the cup near their lips.

  • Do not assume a Pearl person is 'not there' or cannot hear you. They may be processing very slowly. Always speak as if they can understand, and avoid talking about them in front of them.

  • Do not force care on a Ruby person who is actively resisting. If they pull away or say 'no,' back off and try again in 10–15 minutes. Forcing can lead to a physical struggle and injury for both of you.

  • Do not use bright lights or loud noises with a Pearl person. Their nervous system is easily overwhelmed. Use soft lighting, quiet music, and gentle touch.

  • Do not expect a Ruby person to follow multi-step instructions. 'Go to the bathroom, take off your clothes, and get in the shower' is too many steps. Break it down: 'Let’s go to the bathroom' (then wait), then 'Let’s take off your shirt' (then wait).

Practical tools

  • The 'Join and Mirror' Phrase for Ruby

    When a Ruby person is absorbed in an activity, say nothing at first. Just pick up the same tool (a rake, a broom, a cloth) and do the same motion nearby. After 2–3 minutes, you can say softly, 'We’re getting this done, aren’t we?' This validates their focus without demanding a response.

  • The 'Single Sensory Cue' Checklist for Pearl

    Write down 3–5 things that calm the person: a specific song, a warm blanket, a lavender scent, a hand massage with lotion, a rocking chair. Try one at a time. Wait 30 seconds. If no reaction, try a different one. Do not layer cues (e.g., music + lotion + talking) because that can overwhelm.

  • The 'Redirection by Replacement' Tool for Ruby

    If the person is doing something unsafe (like trying to leave the house), don’t say 'Stop.' Instead, hand them something that uses the same motion: a stack of washcloths to fold, a basket of socks to pair, a dusting cloth. Say, 'Can you help me with this? I need it done.'

  • The 'Slow Approach' Script for Pearl

    Step 1: Stand at their eye level, 3 feet away. Step 2: Say their name. Step 3: Wait 5 seconds. Step 4: Say 'I’m going to touch your hand now.' Step 5: Wait 3 seconds. Step 6: Gently place your hand under theirs. Step 7: Wait 10 seconds before doing anything else. This gives their brain time to process.

  • The 'State Check' Log

    Keep a simple notebook or a note on your phone. Every 2–3 hours, write: 'Ruby' or 'Pearl' and one word about what they were doing (e.g., 'Ruby - walking,' 'Pearl - staring'). Over a week, you will see patterns—times of day when they are more Ruby or more Pearl—and you can plan care around those patterns.

Discuss with your clinician

If a Ruby person’s repetitive behavior becomes aggressive (hitting, kicking, throwing objects), ask the doctor about possible pain, infection, or medication side effects before assuming it is 'just dementia.'

If a Pearl person stops eating or drinking for more than 24 hours, discuss with the clinician whether a swallowing evaluation or alternative nutrition (like thickened liquids or pureed foods) is needed.

If you notice a sudden shift from Ruby to Pearl (or vice versa) over a few hours, especially with fever, confusion, or change in breathing, call the doctor immediately—this could be a sign of delirium from an infection like a UTI.

Ask the clinician about non-pharmacological approaches first for both states, but if sleep is severely disrupted or the person is in danger, discuss whether a low-dose medication might help temporarily.

Related guides

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