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Using the GEMS State Tool for dementia assessment and support

Key points

  • The GEMS State Tool uses gemstone names to describe a person's current abilities, not their losses, making it a positive and practical guide for care.
  • Observe the person's movement, speech, and interaction to identify their state, then adjust your communication and environment accordingly.
  • Use the PAINAD scale to assess pain in non-verbal individuals, especially in later states like Ruby.
  • The hand-under-hand technique gives the person a sense of control and reduces resistance during care tasks.
  • Document the person's state over time to track changes and share with the care team.
  • For first responders, a quick GEMS assessment can de-escalate a situation and improve safety for everyone.

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

Step-by-step

  1. Start by observing the person's current abilities, not their diagnosis. Look at how they are moving, speaking, and interacting. Are they able to follow a simple instruction like 'please sit down'? Are they using words, gestures, or just sounds? Are they calm, anxious, or agitated? This observation is your first step in identifying their GEMS state.

  2. Use the gemstone names as a quick mental checklist. For example, a person in a 'Sapphire' state (early dementia) can usually carry on a conversation, manage their own toileting, and follow multi-step directions with reminders. A person in an 'Amber' state (moderate dementia) may need help with dressing, may repeat questions, and may become easily overwhelmed by noise or too many choices. A person in a 'Ruby' state (advanced dementia) may be unable to speak, may need full assistance with eating and mobility, and may show pain through facial expressions or body tension.

  3. Adjust your communication style to match the person's state. For someone in a 'Sapphire' state, use clear, calm sentences and give them time to respond. For someone in an 'Amber' state, use short, simple phrases, speak slowly, and offer only one or two choices. For someone in a 'Ruby' state, use a gentle tone, touch their hand or shoulder before speaking, and rely on nonverbal cues like smiling or nodding.

  4. Modify the environment to reduce stress. If the person is in an 'Amber' state and seems agitated, reduce noise by turning off the TV or radio. Dim bright lights. Remove clutter from the room. Offer a familiar object, like a favorite blanket or photo, to provide comfort. For someone in a 'Ruby' state, ensure the room is warm enough, play soft music, and avoid sudden movements.

  5. When providing hands-on care, use the 'hand-under-hand' technique. Instead of grabbing the person's hand to guide them, place your hand under theirs, palm up, and let them rest their hand on top of yours. This gives them a sense of control and reduces resistance. This is especially helpful when assisting with eating, dressing, or transferring.

  6. Use the GEMS tool to assess pain in later stages. For a person in a 'Ruby' or 'Amber' state who cannot verbally express pain, use a tool like the Pain Assessment in Advanced Dementia (PAINAD) scale. Observe five indicators: breathing (e.g., labored or noisy), vocalization (e.g., moaning or calling out), facial expression (e.g., grimacing or frowning), body language (e.g., tense or fidgeting), and consolability (e.g., whether they calm down when you speak or touch them). Rate each from 0 to 2, add the scores, and discuss with a clinician if the total is 4 or higher.

  7. Document your observations over time. Keep a simple log of the person's GEMS state at different times of day and in different situations. Note what helped and what didn't. This record is invaluable for tracking changes and for sharing with doctors, therapists, and other care team members. It can also help you decide when to adjust the level of supervision or when to consider new safety measures.

  8. For EMTs and first responders: When you arrive on scene, first assess the person's GEMS state from a distance. Approach slowly, from the front, and use a calm, low voice. Identify yourself and state your purpose in simple terms: 'My name is [name]. I'm here to help you.' Avoid asking 'do you remember me?' Instead, say 'I'm here to check on you.' If the person is in an 'Amber' or 'Ruby' state, avoid touching them without warning. Ask permission: 'May I take your blood pressure?' If they resist, wait a moment and try again with a different approach, like offering a distraction.

What not to do

  • Do NOT try to force the person into a specific stage or label them as 'just stage 5.' This can lead you to overlook their current abilities and needs. Instead, use the GEMS tool to assess their state in the moment and respond flexibly.

  • Do NOT use complex language or ask multiple questions at once. For example, don't say 'Do you want to sit in the blue chair or the green chair, and would you like a drink?' This overwhelms a person in an 'Amber' state. Instead, offer one choice at a time: 'Would you like to sit here?'

  • Do NOT assume that because a person is in a later state, they cannot understand you or feel pain. People in 'Ruby' states often still hear and feel, even if they cannot respond. Always speak to them with respect, explain what you are doing, and watch for signs of pain or discomfort.

  • Do NOT use the GEMS tool as a substitute for medical evaluation. It is a communication and care planning tool, not a diagnostic instrument. If you notice sudden changes in state, such as a person who was in a 'Sapphire' state becoming suddenly confused or agitated, this could be a sign of a medical issue like a urinary tract infection or medication side effect. Discuss with a clinician.

  • Do NOT ignore the person's emotional state. If they are in an 'Amber' state and are crying or angry, do not try to reason with them or tell them to 'calm down.' Instead, validate their feelings: 'I see you are upset. I'm here with you.' Then redirect to a calming activity, like looking at a photo album or listening to music.

Practical tools

  • GEMS State Cards and Workbook

    Teepa Snow's Positive Approach to Care offers a set of cards and a workbook that describe each gemstone state in detail. You can use these cards to quickly identify the person's current state and find suggested strategies for communication, activity, and environment. The workbook includes exercises to help you practice shifting your approach. These are available for purchase online.

  • PAINAD Scale (Pain Assessment in Advanced Dementia)

    This is a simple, printable tool that uses five observable indicators to assess pain in people who cannot speak. Rate each indicator (breathing, vocalization, expression, body language, consolability) from 0 to 2. A total score of 4 or higher suggests pain is likely. Download a free copy from the Alzheimer's Association or other dementia care websites. Keep it in your care binder or first responder kit.

  • Functional Assessment Staging Test (FAST)

    While the GEMS tool is more positive, the FAST scale is a widely used, validated tool that can help you track functional decline over time. It is especially useful for determining when to consider hospice care or memory care placement. You can find a free version online. Use it alongside the GEMS tool for a fuller picture.

  • Caregiver Observation Log

    Create a simple notebook or digital document where you record the person's GEMS state at different times of day, along with notes on what triggered changes (e.g., a bath, a visitor, a change in medication). This log helps you identify patterns and prepare for medical appointments. Include a column for 'what helped' so you can build a personalized toolkit.

  • Hand-Under-Hand Technique

    This is a physical technique, not a product. When you need to guide the person's hand (e.g., to help them eat or brush their teeth), place your hand under theirs, palm up, and let them rest their hand on top. This gives them a sense of control and reduces resistance. Practice this with a willing partner before trying it in a stressful moment.

  • Calming Environment Checklist

    Create a checklist for each GEMS state. For 'Amber': reduce noise, dim lights, remove clutter, offer one activity at a time. For 'Ruby': ensure comfortable temperature, play soft music, use gentle touch, avoid sudden movements. Post this checklist in the person's room or in your first responder bag.

Discuss with your clinician

Ask your doctor: 'Based on the GEMS state I'm observing, are there any medical conditions that could be causing a sudden change in state, such as a urinary tract infection or medication side effect?'

Ask your doctor: 'What is the best way to use the PAINAD scale to assess pain in my loved one, and when should I give a pain reliever versus calling you?'

Ask your doctor: 'Are there any medications or treatments that are specifically recommended or contraindicated for the GEMS state my loved one is in, especially for Lewy body dementia?'

Ask your doctor: 'How often should I reassess my loved one's state, and what changes should prompt an urgent medical evaluation?'

Ask your doctor: 'Can you recommend a local occupational therapist or dementia care specialist who can help me apply the GEMS tool in our home?'

Related guides

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