About Dementia: Progression and Teepa's GEMS

The GEMS®: Brain Change Model
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The only constant with dementia, or brains in general, is that they are ever-changing. All humans experience brain change every day. This GEMS Model, developed by Teepa Snow and based on the Allen Cognitive Scale, recognizes the shifts in our skills and abilities in any given moment. With dementia, while the progression, pattern, and changes may look very different for each type of dementia, the movement through the GEMS is somewhat predictable. Your understanding of the remaining abilities at each step of this journey can make a world of difference.

"Just like gems, each person is precious, valuable, and unique, and given the right setting and care, can shine." - Teepa Snow

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Sapphire ~ True Blue ~ Optimal Cognition, Healthy Brain

True to self: personal preferences remain basically the same
Can be flexible in thinking and appreciate multiple perspectives
Stress/pain/fatigue may trigger Diamond state: back to Sapphire with relief
Able to suppress and filter personal reactions: chooses effective responses
Selects from options and can make informed decisions
Processes well and able to successfully transition
Aging doesn’t change ability: processing slows, more effort/time/practice needed


"My brain is healthy - true blue. If I am aging normally or distressed, it may be hard for me to find words. I can describe what I am thinking so you understand. I may talk to myself because I am giving myself cues and prompts. I can learn new things and change habits, but it takes time and effort. Honoring my choices and preferences, when possible, is important. I need more time to make decisions. Give me the details and let me think about it before you need an answer. I am able to remember plans and information but supports are helpful. I may like specific prompts such as notes, calendars, and reminder calls. Health changes in vision, hearing, balance, coordination, depression, anxiety, pain, or medication may impact my behavior, but my cognitive abilities remain the same."

Diamond ~ Clear and Sharp ~ Routines and Rituals Rule

Displays many facets: behavior and perspective can shift dramatically
Prefers the familiar and may resist change: challenged by transitions
More rigid and self-focused; sees wants as needs, when stressed
Personal likes/dislikes in relationships/space/belongings etc, become more intense
Reacts to changes in environment; benefits from familiar; functional/forgiving
Needs repetition and time to absorb new/different information or routines
Trusted authority figures can help: reacts better when respect is mutual


My overall cognition is clear and sharp. When happy and supported, I am capable and shine in my abilities. When distressed, I can be cutting and rigid and may see help as a threat. I have trouble seeing other points of view and may become less aware of boundaries or more possessive about my relationships, personal space, and belongings. I have many facets so people see me differently depending on the situation. This can cause conflict among my family, friends, or care team as it’s hard to tell if I am choosing my behavior or truly have limits in my ability. I can socially engage and have good cover skills. People will vary in their awareness of what is happening to me. I want to keep habits and environments as they have always been, even if they are problematic for me or others. I am often focused on the past, personal values, or finances. I will need help to make changes in my life; it’s hard for me. I can be in a Diamond state for reasons other than dementia.

Emerald ~ Green and On the Go With a Purpose ~ Naturally Flawed

Sees self as able and independent, with limited awareness of changes in ability
Lives in moments of clarity mixed with periods of loss in logic/reason/perspective
Understanding and use of language change: vague words and many repeats
Cues and support help when getting to/from places and doing daily routines
Awareness of time, place, and situation will not always match current reality
Strong emotional reactions are triggered by fears, desires, or unmet needs
Needs to know what comes next: seeks guidance and assistance to fill the day


I am flawed; it is part of being a natural emerald. I tend to be focused on what I want or need in this moment and may not be aware of my own safety or changing abilities. I can chat socially, but I typically miss one out of every four words and cannot accurately follow the meaning of longer conversations. I won’t remember the details of our time together, but I will remember how your body language and tone of voice made me feel. I may hide or misplace things and believe someone has taken them. My brain will make up information to fill in the blanks, which makes you think I am lying. If you try to correct me or argue, I may become resentful or suspicious of you. I am not always rational, but I don’t want to be made to feel incompetent. My brain plays tricks on me, taking me to different times and places in my life. When I am struggling, I may tell you, “I want to go home.” To provide the help and assistance I need, you must go with my flow, use a positive, partnered approach, and modify my environment.

Amber ~ Caught in a Moment of Time ~ Caution Required

Focused on sensation: seeks to satisfy desires and tries to avoid what is disliked
Environment can drive actions and reactions without awareness of safety
Visual abilities are limited: focus is on pieces or parts, not the whole picture
What happens to or around an Amber, may cause strong and surprising reactions
Enters others’ space and crosses boundaries attempting to meet own needs
Has periods of intense activity: may be very curious or repetitive with objects or actions
Care is refused or seen as threatening, due to differences in perspective and ability


Like a particle trapped in an amber, I am caught in a moment of time. It may surprise you to see how I take in the world around me. I may not know you or see you as a whole person. I react to you based on how you look, sound, move, smell, and respond to me. I like to do simple tasks over and over and may need to repeatedly move and touch, smell, taste, take or tear items apart. While it may exhaust or frustrate you, it soothes me. I don’t recognize danger; you will have to safeguard my environment. I’m intolerant to discomfort because my mouth, hands, feet, and genitalia are highly sensitive due to changes in my nervous system. Therefore, activities like eating, taking medication, mouth care, bathing, dressing, and toileting may distress me. Please notice my reaction and stop if I am resisting. I can’t help myself and one or both of us may get hurt emotionally and/or physically. If this happens, wait a few minutes, connect with me, and try a different approach; possibly substituting one area of focus for another.

Ruby ~ Deep and Strong in Color ~ Others Stop Seeing What is Possible

Makes use of rhythm: can usually sing, hum, pray, sway, rock, clap, and dance
When moving can’t stop; when stopped can’t get moving: needs guidance and help
Big, strong movements are possible, while skilled abilities are being lost
Danger exists due to limited abilities combined with automatic actions or reactions
Tends to miss subtle hints, but gets magnified facial expressions and voice rhythms
Can mimic actions or motions, but will struggle to understand instructions/gestures
Able to pick up and hold objects, and yet not know what to do with them


As the deep red of a ruby masks detail, my obvious losses make my remaining abilities harder to notice. Although my fine motor skills have become very limited, remember that I am able to move and do simple things with my hands. You will need to anticipate, identify, and respond to all of my needs, even though I may not be aware of them. Plan to create a supportive environment, help with the details of care, and structure my day. Just as a crossing guard directs traffic, you will need to guide my movements and transitions. I can rarely stop or start on my own and switching gears is a challenge. Move with me first, then use your body to show me what you want me to do next, going one step at a time. Hand-under-Hand™ assistance helps me to feel safe and secure and to know what to do. Danger is part of my life, due to losses in visual skills, chewing abilities, balance, and coordination. You can reduce the risks to me, but not eliminate them. I can still have moments of joy when you are able to provide what gives me pleasure.

Pearl ~ Hidden Within a Shell ~ Beautiful Moments to Behold

Will frequently recognize familiar touches, voices, faces, aromas, and tastes
Personhood survives, although all other capabilities are minimal
Understanding input takes time: go slow and simplify for success
In care, first get connected by offering comfort then use careful and caring touch
Changes in the body are profound: weight loss, immobility, systems are failing
As protective reflexes are lost, breathing, swallowing, and moving will be difficult
Care partners benefit from learning the art of letting go rather than simply giving up


While hidden like a pearl in an oyster shell, I will still have moments when I become alert and responsive. I am near the end of my life. Moments of connection create a sense of wholeness and value between us. Use our time together not just to provide care, but to comfort and connect with me. To help me complete life well, it’s important to honor my personhood when making medical or care decisions; please don’t talk about me as though I am not still here. I respond best to familiar voices and gentle rhythmic movements. I am ruled by reflexes and will startle easily. My brain is losing its ability to control and heal my body. Be prepared to see me having difficulty breathing or swallowing. My body may no longer desire food and drink as I prepare to leave this life. I may not be able to stop living without permission from you. Your greatest gift at this time in my life is to let me know that it is okay to go.

All GEMS Can ShinePAC Annual Conference

Dementia Caregiver Guide

This book covers each GEMS® State and the types of support needed as brain change progresses.

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GEMS: Building Skill to Support GEMS 12-Part Series

This 12-part recorded webinar series with Teepa Snow focuses on interaction skills and appreciating the changes the PLwD may be experiencing. Priced Individually at $120. This Special Bundle now just $79 until August 31st!

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Progression of Dementia: Seeing GEMS Not Just Loss (DVD)

Watch Teepa Snow explain methods of care and risk reduction needed during different GEMS states.

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The Living GEMS Wall Poster


Beautiful and thought provoking 22″ x 28″ poster which shares out the characteristics of Teepa’s GEMS®

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The GEMS State Tool


The GEMS State Tool is an in the moment resource for determining GEMS States and choosing an appropriate support response, to help in de-escalating crises and facilitating communication.

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GEMS Resource Card 25-pack


The GEMS Resource Card is an inexpensive tool to help staff and learners build and remember the GEMS progression knowledge.

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Get a free sample of the PAC Resource Cards

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To cite this webpage, please use:

Snow, T. L. (2012).The GEMS®: Brain change model. Positive Approach to Care. https://teepasnow.com/about/about-teepa-snow/the-gems-brain-change-model/.

To cite the book on the GEMS State Model, please use:

Snow, T. (2012) Dementia caregiver guide: Teepa Snow’s Positive Approach to Care techniques for caregiving, Alzheimer’s, and other forms of dementia. Mason, OH: Cedar Village.

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