GEMS® is a staging system for dementia. Teepa Snow, OTR and founder of the Positive Approach to Care® philosophy, recreated the Allen Cognitive system of staging dementia with a positive twist. We can now view our Person Living With Dementia (PLWD) as one of Teepa’s GEMS® rather than on a scale of 1 to 7 or on a scale of mild cognitive impairment to profoundly demented.

Here are six stages of GEMS® that emphasize the abilities that are retained.


At this point in life, we are noticeably slower and may be forgetful — but this change is relatively normal. If you think about the sapphire gem, it is true blue in color and this is us on a good day. We have no dementia, our brains are flexible and we are able to see different points of views.


Early stage dementia is difficult to detect. You may notice some challenges with short-term memory but the PLWD is able to cover their mistakes. Diamonds are one of the most expensive gems and in this stage, the PLWD is focused on finances. Formed under pressure, this gem is rigid, cutting and sharp. They may have difficulty with change in their daily routines, often using their words to cut you.


In a stoplight sequence, green means go and that is exactly what the Emerald stage is about. The PLWD is traveling in time and place. They may revert back to their younger years and think that they have to go home and cook dinner for the family at 3pm as they always did when they were a housewife in their 30s. A true Emerald is flawed but they don’t think anything is wrong with them. Another challenge is word-finding and using vague language. The PLWD wants to communicate but has trouble verbalizing their thoughts and comprehending your speech.


An amber is formed from tree sap. As the sap fossilizes over time, an amber is created. It has tinges of yellow, brown and orange. Similar to the amber gem, the PLWD is caught in a moment of time. In this stage, the PLWD is focused on sensations and what is happening right now in front of them. They have limited safety awareness but high levels of curiosity.


Following the stoplight sequence, red means stop. Fine motor movements of the mouth, eyes, fingers and feet are stopping. However, gross motor movements are preserved. Although skill is lost as fine motor diminishes, strength stays and they’re able to copy your big motions and gestures. Fine motor movements of the eyes presents trouble, with depth perception creating a higher risk for falls. At this stage, a Ruby has very limited peripheral vision — almost equivalent to having monocular vision. With fine motor in the mouth, a Ruby may mumble words but retains automatic social chit chat, rhythm and music.


What does the outside of an oyster shell look like? It’s rough, different shades of gray, calcified and ultimately, not pleasant to look at. How does this relate to the last stage of dementia? Well, a person in the latest stage of dementia has similar attributes. At this stage, a person may be bed-bound, contractures have set in, eyes are mostly closed, words are unintelligible and personal care is increasingly difficult to provide. In other words, the outside shell of this person isn’t a great sight to see. However, with our positive approach to care methods, we are able to give this Pearl the right care and the right setting so their pearl inside can shine.

Caregiver Education & Consultation
Mapuana Taamu, Certified PAC Trainer
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