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

Optimal Cognition, Healthy Brain

"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."

Sapphire ~ True Blue
Routines and Rituals Rule

"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."

Diamond ~ Clear and Sharp
Naturally Flawed

"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."

Emerald ~ On the Go With A Purpose
Caution Required

"Like a particle trapped in 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."

Amber ~ Caught in a Moment
Others Stop Seeing What is Possible

"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."

Ruby ~ Deep and Strong in Color
Beautiful Moments to Behold

"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."

Pearl ~ Hidden Within a Shell

Browse PAC's Most Essential GEMS Resources in our Online Store

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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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