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The GEMS Crisis Tool for First Responders: A Pocket Guide to De-escalation & Assessment

When a person with dementia is in crisis, their brain is sending a distress signal they cannot put into words. The GEMS state tool gives first responders a simple, four-step framework to quickly assess a person's visual, verbal, and touch abilities, then tailor their response — from how many words to use to how fast to move. This isn't about labeling someone; it's about recognizing that a person can fluctuate through different states in a single call, and that with the right approach, you can often guide them back to calm without force or restraint. You have more power than you think — and sometimes your biggest tool is time.

Key points

  • The GEMS tool is a four-step crisis plan: Observe, Discover, Identify, Respond — all based on the person's visual, verbal, and touch skills in the moment.
  • People with dementia can fluctuate through different GEMS states during a single call. Your response must match their current state, not their diagnosis.
  • Your biggest tool is time. Use it to observe before acting. A calm, slow approach often works better than rapid intervention.
  • Pain, infection, constipation, environment, need to urinate, or medication changes (PICKUM) are the most common causes of sudden behavior change. Rule these out first.
  • Use 3-5 word sentences, a low-pitched voice, and visual cues (pointing, holding up objects) to help the person understand and cooperate.
  • If the person is crying, screaming, or hitting, remember: it is a distress signal, not a personal attack. Step back, give space, and use a rhythmic, reassuring phrase.

What Is the GEMS State Tool?

The GEMS tool was developed by Teepa Snow's Positive Approach to Care team as a crisis safety plan for first responders, emergency department staff, and psychiatric units. It is a four-step observational framework designed to help you quickly figure out what is going on with a person in crisis — not by asking them a list of questions, but by watching how they use their eyes, their voice, and their body. The core idea is that dementia is not a single, locked-in stage; people can fluctuate through different 'gems' (like a sapphire, amethyst, or diamond) even within the same call. By identifying which state they are in right now, you can choose a response that actually works with their brain, not against it.

Why It Matters for First Responders

Traditional crisis intervention often relies on verbal commands and rapid action. But a person with dementia may not be able to process language the same way, especially when frightened or in pain. The GEMS tool gives you a way to 'see' what is happening: you observe their visual skills (do they make eye contact? track movement?), their verbal skills (can they answer simple questions? repeat words?), and their touch skills (do they flinch? reach out? hold still?). From those clues, you can deduce what might be wrong — is this a sudden change from their baseline? Could it be pain, infection, constipation, or a medication side effect? The tool then guides you on how many words to use in a sentence, how fast to move, and what visual cues might help them do what you need them to do.

The Four Steps in a Nutshell

The four steps are: (1) Observe — watch the person's visual, verbal, and touch skills without jumping in; (2) Discover — ask yourself what might be going on, and if this is different from their usual state; (3) Identify — name the possible unmet need (pain, fear, confusion, hunger, etc.); (4) Respond — use the specific communication and movement strategies that match their current GEMS state. The tool is designed to be used in the moment, even when you only have a few minutes. As one officer put it, 'Not every call is truly an emergency — sometimes my biggest tool is time.' The GEMS tool helps you use that time wisely.

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

Step-by-step

  1. Step 1: Pause and observe from a safe distance. Do not rush in. Watch the person's eyes: are they looking at you, looking around, or staring into space? Watch their hands: are they fidgeting, gripping something, or relaxed? Watch their mouth: are they speaking, mumbling, or silent? This 10-second scan gives you the first clues about their GEMS state.

  2. Step 2: Use a calm, low-pitched voice. Say your name and role slowly: 'I am Officer [Name]. I am here to help you.' Use only 3-5 words per sentence. Do not ask 'How are you?' — that is too open. Instead, give a simple direction: 'Please sit down.' Or 'Show me your hands.'

  3. Step 3: Match your movement speed to their state. If they are moving slowly, you move slowly. If they are agitated, do not mirror that energy — slow down even more. Keep your hands visible and at your sides. Avoid sudden gestures. If you need to point, use your whole hand, not one finger.

  4. Step 4: Ask one simple yes/no question at a time. For example: 'Are you in pain?' Wait for a nod or a word. 'Do you need water?' 'Is something bothering you?' If they cannot answer, look for non-verbal cues: grimacing, holding a body part, rocking, or pulling away from touch.

  5. Step 5: Check for the 'PICKUM' causes of sudden change: Pain, Infection, Constipation, (environment)K, Urination, Medication change. If the person is acting differently than their baseline, one of these is likely. Ask family or caregivers if they are present: 'Is this normal for them? What changed?'

  6. Step 6: Use visual cues to help them cooperate. Hold up a chair and say 'Sit here.' Point to the door and say 'This way.' If they need to take medication, only assist if it is prescribed for them, you are authorized to administer it, and you have verified the correct medication, dose, and time. If unsure, consult a healthcare provider before giving any medication. Show them the pill and a glass of water. Their brain may understand what it sees better than what it hears.

  7. Step 7: Give them a sense of control. Instead of 'You have to come with me,' try 'Will you walk with me? I will go with you.' Offer a choice between two safe options: 'Do you want to sit in the front seat or the back seat?' or 'Do you want your jacket or a blanket?'

  8. Step 8: If the person is crying, screaming, or hitting, remember: this is a distress signal, not a personal attack. Do not take it personally. Step back if needed, give them space, and use a soft, rhythmic voice: 'I hear you. I am here. You are safe.' Repeat the same phrase. If the behavior escalates or becomes physically dangerous, stop and call for backup immediately.

  9. Step 9: If you cannot de-escalate within a few minutes, call for backup — especially if the person has a history of violence or if you suspect a medical emergency (like a stroke or infection). Paramedics and hospital staff are trained to handle these situations and can also document the behavior for future care planning.

  10. Step 10: After the crisis, document what you observed: the person's GEMS state (e.g., 'sapphire' or 'amethyst'), what you tried, and what worked. This information can help the next responder, the emergency department, and the family understand the person's needs better.

What not to do

  • Do not shout or use a commanding tone. A loud voice can trigger a fight-or-flight response in a brain that cannot process the words. Instead, use a calm, low-pitched voice and speak slowly.

  • Do not ask multiple questions at once. Questions like 'What is your name, where do you live, and what happened?' will overwhelm them. Ask one simple question, wait for an answer, then ask the next.

  • Do not grab or restrain unless there is an immediate safety threat. Physical touch can be perceived as an attack. If you must touch, do so slowly and announce it: 'I am going to touch your arm now to help you stand.' If the person resists or becomes more agitated, stop and reassess.

  • Do not assume they are intoxicated or mentally ill. Dementia can look like intoxication: slurred speech, unsteady gait, confusion. Always rule out a medical cause first. Ask family or check for a medical ID bracelet.

  • Do not argue with them. If they say something that is not true (e.g., 'I need to go pick up my kids from school' and they are 80 years old), do not correct them. Instead, validate the feeling: 'I hear you are worried about your kids. Let us figure this out together.'

  • Do not leave them alone if they are agitated or in an unsafe environment. If you must step away, ensure someone else is watching them, or move them to a safe, quiet area first.

Practical tools

  • The GEMS Quick-Reference Card

    A laminated card you can keep in your pocket or vehicle that lists the four GEMS states (Sapphire, Diamond, Emerald, Amethyst) with key clues for each: typical visual skills, verbal skills, touch skills, and recommended response (number of words, speed of movement, type of visual cue). You can print one from the Positive Approach to Care website or create your own based on the training.

  • The PICKUM Checklist

    A mental checklist for sudden behavior changes: Pain, Infection, Constipation, Environment (too loud, too bright, too cold), Urination (needs bathroom), Medication change. Run through this list in 30 seconds. If you find a likely cause, address it first — for example, if pain is suspected, start with comfort measures (repositioning, warm/cool compress) and contact a healthcare provider before giving any medication. If you are a healthcare professional, follow your pain management protocol. Help them to the bathroom, or move them to a quieter room.

  • The 'Three-Word Phrase' Script

    When a person is highly agitated (Amethyst state), use only three-word phrases. Examples: 'Sit down please.' 'Drink some water.' 'I am here.' 'You are safe.' 'Breathe with me.' Repeat the same phrase until they respond. Do not add new information until they calm down.

  • The Visual Cue Kit

    A small kit you can carry: a photo of the person with their family (to help orient them), a simple map of the area (point to 'home' or 'hospital'), a soft object like a stress ball (to give their hands something to do), and a bottle of water. These items can be offered without words and can help ground a person in crisis.

  • The 'Baseline Question' for Family

    If family is present, ask: 'What is their usual GEMS state? Is this different from normal? What usually helps them calm down?' If no family is present, ask the person: 'Is this how you usually feel?' or 'Has something changed today?' Their answer (even a nod or shake) can guide your next step.

  • The 24/7 Helpline Number

    Keep the Alzheimer's Association 24-hour helpline (1-800-272-3900) in your phone. You can call them during a crisis for real-time advice on how to communicate with the person, what to say, and what resources are available in your area. They are trained to support both caregivers and professionals.

Discuss with your clinician

If the person is on antipsychotic or sedative medication, ask their doctor or the facility nurse: 'Is it safe to give a PRN dose during a crisis? What is the usual dose and route?'

If the person has a history of falls or fractures, ask: 'What is the safest way to help them stand or move without causing injury?'

If the person has a known heart condition or is on blood thinners, ask: 'Are there any signs of stroke or internal bleeding I should watch for during a crisis?'

If the person has a feeding tube or other medical device, ask: 'How do I safely manage this device during transport or de-escalation?'

If you suspect pain and are considering medication, ask the doctor: 'What non-pharmacological comfort measures should I try first? If medication is needed, what is the correct type, dose, and timing for this person?'

If the person needs medication during the crisis, ask: 'Can you confirm the medication name, dose, and time? Is it safe to administer now given their current state and other medications?'

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