What are Dementia Gem States by Teepa Snow?

The GEMS® State Model is a care approach used by dementia care practitioners to inform and guide the type and level of support provided to people living with Alzheimer’s disease and dementia.

The GEMS® State Model For Dementia Care

Dementia is a progressive brain disease and the fundamental principal behind the GEMS® State Model of care. Since brain disease progresses in different ways and causes a variety of symptoms and behaviors that are unique to every person, the approach to dementia care must be equally dynamic.

Unlike the traditional one-size-fits-all approach, the GEMS® State Model encourages caregivers to see a person with dementia as precious and unique with distinctive characteristics like gemstones and modify their expectations, support and care according to a specific gem-like state of mind.

Insight into the various gem states helps caregivers understand the perspective, skills and abilities of people with dementia and provide different levels of support as these traits evolve.

Creating A Positive Dementia Care Culture

Teepa Snow, MS, OTR/L, FAOTA, has made GEMS® the foundation of her renowned Positive Approach To Care® training and education program.

According to Teepa Snow, the gems analogy is designed to diminish negative stereotypes associated with dementia to create a more positive dementia care culture. She believes GEMS® are not distinct stages in which the person with dementia deteriorates. Instead, they are states one can move through moment-to-moment.

This distinction is important because it allows caregivers to focus on what an individual with a progressive disease like dementia can do rather than what they cannot do.

Without intervention, people with dementia may become isolated or withdrawn. As the person with dementia loses the ability to communicate, some caregivers are more inclined to do “for” rather than do “with.”

In the GEMS® State Model, caregivers are trained to see dementia through the lens of evolving abilities rather than lost abilities through the traditional static stages. Caregivers promote higher levels of engagement and participation while minimizing distress and other negative symptoms and behaviors of dementia.

Most importantly, the GEMS® State Model emphasizes abilities that have been retained over abilities that have been lost in the person with dementia to promote safe and productive engagement.

GEMS® States and Colors

According to Positive Approach to Care® educational materials, each gem state is associated with certain abilities and behaviors. By recognizing the characteristics, abilities and behaviors associated with each gem state, caregivers can engage in an appropriate manner that help the person with dementia “shine” like a gemstone.

Six distinctive gemstones and colors are used to represent the GEMS® states and provide a foundation for understanding dementia behaviors. Equipped with this knowledge, caregivers can manage both the environment and interpersonal interactions as well as cues adapted to the various gem states.

The six major gem states and associated characteristics include:

Sapphire (blue) – Flexible and adaptable
Diamond (clear) – Lives by habit and routine
Emerald (Green) – Travels in time and place
Amber (Yellow-Orange) – Lives in the moment
Ruby (Red) – Retains strength over skills
Pearl (White) – Ruled by reflexes

Retained Abilities in GEMS®

Due to the nature of brain disease, the abilities and acuity in people with dementia constantly change, not only from day to day, but time of day. The GEMS® States model takes this fact into consideration and offers caregivers a framework for identifying retained abilities in combination with body, interpersonal and awareness skills.

For example, a person in the emerald state can mistake one time and situation for another while a person in the diamond state is more likely to get lost in unfamiliar places.

Vision and the GEMS® State Model

Visual acuity is impacted by Alzheimer’s disease and dementia. GEMS® states are associated with changing vision to help caregivers understand how the person with dementia perceives and experiences the world visually.

For example, a person in the ruby state may have difficulty processing multiple images at once or lack the ability to judge distance without the use of one’s hands. In this state, caregivers may find it helpful to serve food on brightly colored plates that are easier to see.

Verbal Abilities and the GEMS® State Model

In the GEMS® State Model, verbal abilities, including vocabulary, comprehension, and speech change in severity according to gem states. For example, a person in the amber state may understand simple phrases but using words to describe a specific need is challenging.

Sensation and the GEMS® State Model

For the person with dementia, sensory awareness changes as the disease progresses. Sight, hearing, smell, taste, pressure, temperature, and pain—all the senses are impacted by the sensory changes caused by brain disease.

The GEMS® State Model provides guidance on how to manage various stimuli based on a predicted reaction and gem state to minimize frustration and distress caused by sensory changes. For example, individualized music may be used to calm an agitated person or the aroma of food cooking in a crock pot may stimulate the appetite.

The idea is to modify the environment or activity according to an individual’s tolerance level to avoid over-stimulation and under-stimulation. Behavioral research on this topic is the driving force behind purpose-built memory communities.

Using GEMS® in Memory Care Communities

Memory care communities that practice the GEMS® State Model, including Serenades Memory Care by Sonata, recognize the chemical and structural changes in the brain and tailor care in accordance with dementia and Alzheimer’s disease progression.

Serenades Memory Care is one of several specialized memory care communities that practice Teepa Snow’s Positive Approach To Care® using the GEMS® State Model.

According to Sonata’s Director of Team Development and Training and Nationally Certified Dementia Care Practitioner (NCCDP) Julie Fernandez, Serenades dementia care practitioners are extensively trained to modify their behavior and support to help people with Alzheimer’s disease experience a better quality of life.

For example, in the amber state, Serenades’ staff have to be able to read body language to anticipate needs even as the resident with dementia may not realize what the unmet need is that is causing the distress. Intensifying opportunities of engagement at this stage to prevent behavior that causes them to become agitated is a useful technique at this stage. Residents can be redirected to safe activities like sorting and board games.

Memory care residents in the emerald state typically have an increased desire to move so Serenades caregivers are better prepared to manage the wandering instinct associated with Alzheimer’s disease.

A person in the ruby state will likely have less coordination, so Serenades caregivers are trained to use calming language and cues to mitigate stress and anxiety caused by dementia.

When caring for someone in the pearl state, the gem state associated with the most advanced sensory challenges, Serenades caregivers are trained to provide additional prompts for eating and drinking to prevent weight loss caused by dementia.

According to Julie, connecting is very important in the pearl state. The pearl state is associated with a hard outer shell, but the human being—the beautiful pearl—remains on the inside even though it is difficult to see. You have to find that pearl inside the failing body. We teach our caregivers to connect with the pearl through touch to help a resident feel loved and comforted because they may be nearing the end of life.

Dementia Stages Versus Gem States

Talking about dementia behaviors as gemstones is so much more comforting to our families than traditional stages, she explained. Terms like “stage 7” and “late-stage dementia” remove the person from the conversation. We tell our families it doesn’t matter what they (their loved one) can’t do anymore. Let’s talk about what they can do.

The purpose-built architectural features of Serenades Memory Care support resident engagement in all states and stages of dementia, she said. The environment was created specifically for people with memory challenges so caregivers can focus more on providing true person-directed care using GEMS® rather than worrying about safety. Safety and security are built into the architecture of Serenades Memory Care.

Who Is Teepa Snow?

Teepa Snow is an international leader in dementia care education and advocacy as well as founder of Positive Approach To Care® (PAC), which provides resources and training related to dementia and brain change. PAC resources help health care professionals, organizations, families, and people living with Alzheimer’s disease and dementia gain understanding and insight into brain change while providing the practical skills needed to thrive.

To learn more about programming at Serenades Memory Care,

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Guide to Finding the Right Memory Care Community for Your Loved One

Looking for the right memory care community can be challenging. You want to make sure you find the best place for your loved one, while dealing with a range of emotions. The entire family feels the impact when a loved one is diagnosed with Alzheimer's or a related form of dementia.