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Adapting Communication to Each GEM State: A Practical Guide for Caregivers

When dementia changes the brain, the person you care for shifts through different GEM states—each with its own communication needs. This guide helps you recognize which state your loved one is in and gives you concrete words, actions, and tools to connect with them in that moment. You don't have to guess; there are proven techniques that make interactions calmer and more meaningful, no matter the stage.

Key points

  • Match your communication to the person's current GEM state, not their past self.
  • Use the GEMS State Tool (app or chart) to quickly identify the state and get tips.
  • For Amber and Ruby states, use one-step instructions and non-verbal cues.
  • Never argue, correct, or rush—validation and calm tone build trust.
  • Reassess the state each time you interact; it can change hour to hour.
  • Create simple tools like a 'Two-Choice' card or a sensory kit to reduce verbal overload.

What Are GEM States and Why Do They Matter for Communication?

The GEM states model, developed by Teepa Snow, describes the changing abilities of a person living with dementia using gemstone names: Sapphire (early, mostly independent), Emerald (mild cognitive changes, still social), Amber (moderate, needs more cues), Ruby (advanced, very limited verbal), and Diamond (end-stage, sensory-focused). Each state reflects how the brain is processing information, language, and emotion. Communication techniques that work for a Sapphire will fail with a Ruby, and vice versa. The key is to match your approach to the person's current state, not their past abilities.

Why Matching Communication to the State Reduces Frustration

When you use language or expectations that are too complex for the person's current GEM state, you trigger confusion, anxiety, or agitation. The brain in dementia cannot keep up with rapid speech, abstract questions, or multiple-step instructions. By adapting your tone, word choice, pacing, and body language to the person's state, you create a 'just-right' challenge that feels safe and doable. This builds trust and makes the person more willing to move forward with you—whether in conversation or in a care task. The goal is connection, not correction.

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

Step-by-step

  1. 1. Identify the person's current GEM state before you speak. Use the GEMS State Tool (a visual chart or app) to quickly assess: Are they Sapphire (independent, logical), Emerald (social but forgetful), Amber (needs simple cues, may repeat), Ruby (few words, needs gestures), or Diamond (sensory, non-verbal)? This step sets your baseline.

  2. 2. For Sapphire state: Use normal adult conversation but avoid open-ended questions about recent events they may not remember. Say, 'I need to check your blood pressure now. Let's walk to the chair together.' Keep it direct but respectful.

  3. 3. For Emerald state: Use a warm, friendly tone with short sentences. Offer choices, but only two options. For example, 'Would you like to wear the blue sweater or the red one?' Avoid asking 'What do you want to do?'—that's too vague.

  4. 4. For Amber state: Use very simple, one-step instructions. Pair words with a gentle touch or a visual cue. Say, 'Hold this cup' while placing your hand over theirs. Avoid reasoning or explaining—just guide.

  5. 5. For Ruby state: Use mostly non-verbal communication—soft eye contact, a gentle smile, and slow, simple gestures. Speak in single words or very short phrases like 'Time to eat' while pointing to the spoon. Let silence be okay.

  6. 6. For Diamond state: Focus on sensory connection—soft music, a familiar scent, or gentle rocking. Use a calm, rhythmic voice with no expectation of a verbal response. Your presence and touch are the communication.

  7. 7. After each interaction, reflect: Did the person respond with calm or agitation? If they seemed distressed, you may have misjudged their state or used too many words. Adjust next time by simplifying further.

  8. 8. Use the 'Positive Approach to Care' (PAC) technique: approach from the front, get to their eye level, offer your hand, and wait for them to acknowledge you before speaking. This works across all states but is critical for Amber and Ruby.

What not to do

  • Do not ask 'Do you remember me?' to someone in Amber or Ruby state. It puts pressure on a failing memory and can cause shame or agitation. Instead, introduce yourself warmly each time: 'Hi, it's me, Sarah. I'm here to help you.'

  • Do not use baby talk or a high-pitched voice for any state. Even in Diamond state, a respectful, calm tone is better. Patronizing speech can trigger anger or withdrawal. Speak with dignity, not like a child.

  • Do not give multiple-step instructions to someone in Amber or Ruby state. Saying 'First take off your coat, then hang it up, then come sit down' will overwhelm them. Break it into one step at a time, with a pause between.

  • Do not correct their words or facts if they are in Emerald or Amber state. If they say 'I want to go home' when they are already home, don't argue. Instead, validate the feeling: 'You miss home. Tell me about it.'

  • Do not rush or use a loud voice. Speed and volume increase anxiety across all states. Slow down, lower your pitch, and allow extra time for them to process. Silence is not failure—it's processing time.

  • Do not assume the state is fixed. A person may shift from Emerald to Amber within the same day due to fatigue, illness, or environment. Reassess each time you interact.

Practical tools

  • The GEMS State Tool (app or chart)

    A visual reference that shows each gem state with typical abilities, communication tips, and care strategies. Keep a printed copy on the fridge or download the app (from Teepa Snow's Positive Approach to Care). Use it daily to remind yourself what to expect and how to adapt.

  • The 'One-Step' Phrase Bank

    Create a small notebook or note on your phone with simple, one-step phrases for each state. For Amber: 'Sit here.' 'Drink this.' 'Hold my hand.' For Ruby: 'Eat.' 'Walk.' 'Rest.' Practice saying them with a calm, low voice. This reduces your own stress in the moment.

  • The 'Approach from the Front' Checklist

    Before speaking, run through this: (1) Approach from the front, not the side or behind. (2) Get to eye level (kneel or sit). (3) Smile softly. (4) Offer your hand, palm up. (5) Wait for eye contact or a nod. (6) Speak slowly. This works for all states and prevents startle reactions.

  • The 'Two-Choice' Card

    For Emerald and Amber states, have a small card or visual with two simple pictures (e.g., a glass of water and a cup of tea). Hold it up and say, 'Water or tea?' while pointing. This reduces verbal overload and gives a clear, concrete choice.

  • The 'Sensory Kit' for Diamond State

    A small bag with items that engage the senses: a soft fabric square, a lavender sachet, a smooth stone, a playlist of familiar songs. Use these to connect when words fail. Offer one item at a time, and watch for a calming response (slower breathing, relaxed face).

Discuss with your clinician

If the person suddenly shifts to a lower GEM state (e.g., from Emerald to Ruby in a day), discuss with a doctor—this could signal an infection, medication side effect, or other medical issue.

Ask your clinician about using the GEMS State Tool as part of care planning. Some facilities may not be familiar with it; you can request a referral to a dementia-trained occupational therapist.

If the person becomes aggressive when you use simple language, discuss with a behavioral health specialist. It may be pain, fear, or a need for a different approach, not a failure of technique.

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