Sheila J. Bosch, PhD, LEED AP, EDAC Rosalyn Cama, FASID, EDAC Eve Edelstein, MArch, PhD, EDAC, AssocAIA, F-AAA

It has been suggested that color has a therapeutic effect, although few empirical observations exist. Edelstein et al. (2008) reviewed citations from biomedical literature and found that while influence of the colored light on health was supported by several decades of rigorous research into circadian rhythms, there was a paucity of consistent data on the influence of applied color on health.

Tofle et al. (2004) note that “oversimplification of the psychological responses to color pervades the popular press, and direct applicability to architecture and interior design of healthcare settings seems, “oddly inconclusive and nonspecific” (p. 5). They assert, “The attempt to formulate universal guidelines for appropriate colors in healthcare settings is ill advised (p. 5).”

Schuschke and Christiansen (1994) also found that “no compelling scientific reasons can be given for coloration in the hospital.” For example, their study of 68 patients found heterogeneity in their choice of sick-room color in clinics and could not support specific or absolute color solutions. Nonetheless, in all 68 subjects, a preference for light colors for all objects such as ceiling, wall, floor, curtain, furniture, and linen were reported.

Color for Signage in Healthcare Settings

For many years, color has been used to inform wayfinding. Gibson, MacLean, Borrie, and Geiger (2004) examined the behavior of 19 (all male; mean age of 84.3 (SD = 4.1) residents in a long-term care dementia unit following the renovation of the unit. The renovation was intended to make the unit feel less “institutional” and create an entrance to each room that was more visibly distinct, using “color, texture and cosmetic architectural structure.” Patients who were able to find their way to their rooms were interviewed using five free-response questions that allowed residents to share information regarding environmental cues that assisted them in this task. Residents who could not successfully find their room were not interviewed.

Thirteen of the 19 participants reported that color was used to help them find their rooms. Structure (e.g., room number, name plate) was the second most often reported cue (12 of 19 participants). Generalization of results from this study are limited by its small sample size, narrow age range, and the medical condition of participants.

The use of color and graphic images may be vital factors in healthcare design. As hospitals have a wide range of visitors and patients with different levels of visual impairments and disabilities, making comprehensible signage is essential. In the United States, color coding has been developed to reduce confusion and aid in decision making by specifying color stereotypes: warning information in red, caution information in yellow or amber, and advisory information in another color clearly discriminable from red or yellow/amber.

ANSI and the ISO have introduced similar universal color-coding standards (ISO 3864-1) and include green for safety. These ISO standards for safety colors, signs, and graphics are specifically designed to reduce accidents and injuries in public facilities, such as hospitals, worldwide. However, color in signage must be used with caution. For example, red-green color blindness and red-blue combinations can be difficult to resolve and have been shown to cause eyestrain thought to be due to the different focusing levels required as these colors are on the opposite end of the visible spectrum of the human eye.

The Americans With Disabilities Act reviews signage guidelines, recommending that the finish and contrast of the characters and background of signs be eggshell, matte, or other nonglare finish, and that characters and symbols contrast with their background by 70%.

Rousek and Hallbeck (2011) report that with normal vision, 38% of participants had trouble recognizing signage during a wayfinding task; most commonly small lettering (18%), insufficient illumination (18%), insufficient contrast between the background and letters (10%), and mounting signage too high (8%). Studies simulating visual impairment by having subjects wear goggles showed many participants (70%) in their wayfinding study had trouble recognizing signage. The most commonly reported issues were improper illumination (38%), unexpected positioning (36%), and failing to notice the signage (14%). Sixty of the participants felt the signs were too small.

They studied the use of signage color in the healthcare setting. Participants (n = 50) with healthy eyes were asked to respond to various pictograms (some with color and some black and white only) using three questionnaires, both with and without goggles designed to simulate 5 types of visual impairments (diabetic retinopathy, glaucoma, cataracts, macular degeneration, or hemianopsia).

The researchers found that color contrast improved signage comprehension and concluded from the limited set of colors and graphics tested (black, blue, white, red, green), that a combination of red and white backgrounds with black font was preferred. It should be noted that the font, size, scale, and color contrast are very important, along with the intelligibility of the design graphic itself.

Consider functional factors:

  •  Effect of lighting and materials on color.
  •  Ages of people who will use the space.
  •  Is the space for patients, staff, or visitors, and what is the typical length of time these people will be exposed to these colors?
  •  The nature and severity of the illness.
  •  The impact of illness or medical condition on color blindness or perception.
  •  Suitability of color palette for women, men, and children.
  •  Types of tasks: amount of contrast desired for the level of visual acuity and amount of contrast required.
  •  Is the goal to emphasize or to camouflage?
  •  Is the goal to organize spaces using color as the cue?
  •  How much contrast is desirable?
  •  Interaction of texture can cause the same color to look different.
  •  Use as cueing device in wayfinding.
  •  Use to denote hazards or warn of danger.
  •  Geographic and cultural bias: In northern climates with long, harsh winters, warm colors might be more appropriate than cool; in the West, the quality of light is a warmer and more intense color than in the East; in tropical areas, strong saturated colors (hot pink, orange, peacock, purple, lime) are often favored.

The use of color has long been one of the most subjective aspects of interior design and especially so in healthcare settings. This may account for the fact that many of the newer hospitals are devoid of color. For those who seek validation through evidence-based research, it is very difficult to design color studies for the actual setting of a healthcare facility, therefore, there is little that is definitive in the way that practitioners might wish to find clear principles that can be applied to the healthcare environment.

Nevertheless, there is much value in the assembly of studies noted in this paper to enable the confident practitioner, armed with basic color theory, to understand the sensitivities of each type of patient and each setting and to be able to successfully enhance patients’ experiences. Design practitioners educated and trained in the application of color theory and the principles noted above may be timid because the risk of criticism is high. Risk seems to be reduced by the specification of a neutral color palette but can also be reduced with proper evidence to support a broader palette.

The lack of color (white walls) is unfamiliar to some, considered modern by others, and, for many years, has been one of the hallmarks of what has been referred to as an “institutional” environment. Consider this publication a baseline that perhaps will stimulate much more research about the influence of color. But for now, go forth and use color. The more you do it the more confident you will become.

Source: Bosch, S. J., Cama, R., Edelstein, E., & Malkin, J. (2012). The application of color in healthcare settings. Concord, CA: The Center for Health Design.ISO 690

Design for dementia builds on design that is beneficial for older people in general. This section provides a brief summary of the impairments of old age for which design can help.

Designing effectively for people with dementia involves first appreciating that they are mainly older, indeed often very old people, who are likely to have the same impairments as their contemporaries. These impairments will often affect their sight, hearing and mobility. The difference is that they may not be aware that they have them.


Photo by Victor Freitas on

The prevalence of blindness and visual impairment increases exponentially with age (World Blind Union, 2011). Older people’s eyes are likely to have thick- ened lenses, which will impair their ability to see colour, make glare harder to tolerate and slow their ability to adjust to different light levels. Cataracts may affect their ability to see – and because of their dementia these may go unreported and untreated. They may have macular degeneration, resulting in loss of detailed vision. This has implications for reading, watching TV, eating, identifying hazards and recognising faces. Some people will have glaucoma, which affects peripheral vision, impacting mobility and making it harder to detect hazards. Dementia itself is likely to adversely affect the parts of the brain used to construct the visual scene.

People with sight impairment and dementia need a lot of light, combined with contrasting tones (rather than colour itself ) to ensure objects are visible.


Over 70% of people aged over 70 have a hearing impairment (Action on Hearing Loss, 2011). There are two main forms of impairment. Conductive loss occurs when sound is not conducted efficiently through the outer ear canal to the eardrum and the ossicles of the middle ear. Sensorineural loss is caused by damage to the inner ear or the nerve pathways to the brain. Presbycusis is a form of gradual, age-related sensorineural hearing loss.

Older people commonly experience a combination of both conductive and sensorineural hearing loss. As well as a general deterioration in their ability to hear, both types of impairment lead to specific difficulties. These include reduced ability to hear high frequency sound; an oversensitivity to low fre- quency sound; and an impaired ability to filter out unwanted sound. The need to wear hearing aids can further impacts on the hearing difficulties of many older people. For example, if batteries are not replaced or the tubes become obstructed by wax, hearing aids may become a hindrance to hearing. The result can be a real struggle to remain calm, concentrate and have a normal conversation with others.
A person with dementia may also have tinnitus, which is a perception of sound where there is none externally. Vestibular disorders of the ear (e.g. Ménière’s disease) can lead to imbalance, dizziness and hearing changes.

People with hearing impairment and dementia need a quiet environment with extra attention paid to acoustics. Measures should be taken to avoid or prevent sources of noise, and to provide sound absorption.

Circadian rhythm (body clock)

Photo by Buenosia Carol on

Many older people have difficulty regulating their body clock, and this is especially common for those with dementia. They can sleep a lot during the day and be awake at night. Television and computer use at night can also add to this problem due to emission of ‘blue’ light (Giuliano, 2012). For many people, problems with their body clock can be remedied by exposure to high levels of light in the morning. Daylight (or an equivalent light with high blue content), combined with dark and quiet conditions at night, is extremely useful. Clocks can be a helpful starting point for some people who have become disorientated in terms of time (see section 6).

Musculoskeletal problems

The majority of older people have some problems relating to their muscles and joints. They may stoop; experience pain; have impaired reach and grip; find it hard to balance; or experience general mobility problems. Vitamin D is essential for good bone and muscle health, and the best and cheapest way to get it is to expose skin (e.g. arms and legs) to sunlight for around ten minutes a day between April and September (avoiding exposure to midday sun). This underlines the importance of easy access to an outside space.


The Dementia Services Development Centre Iris Murdoch Building (2013).
University of Stirling, Stirling

  • Provide sensory stimuli that is noninvasive in character to draw our attention away from the initial feeling state to an external focus.
  • Facilitate physical and psychological movement with pathways and/or vistas through to a variety of types of spaces, thereby assisting a shift in perspective.
  • Create areas for safe seclusion as well as social interaction to help think and work through issues.
Photo by Tom Fisk on

Specific suggestions to achieve these goals are:

  1. Lush, colorful planting that is varied and eye catching so as to suggest the image of a gar den. Over and over, trees, plants, and greenery were cited as the most significant helpful characteristic.
  2. Appropriate plant selection, with special attention given to cultural requirements and correct placement in the garden, is one of the essential elements of a therapeutic garden environment, as dying and unhealthy plants have a negative psychological impact on those observing them.
  3. Flowering trees, shrubs, and perennials provide a sense of seasonal change that reinforces one’s awareness of life’s rhythms and cycles.
  4. Trees whose foliage moves easily, even in a slight breeze, draw the user’s attention to the patterns of color, shadows, light, and movement. This was described by interviewees as a soothing and meditative experience.
  5. Features to attract birds — such as a fountain or birdbath, a bird feeder, trees appropriate for roosting or nesting — stimulate the senses and help to lift people’s spirits.
  6. Contrast and harmony in texture, form, color, and arrangement of plant materials provide a variety that holds the attention and helps to draw our focus away from ourselves.
  7. Plant species that attract butterflies call attention to the ephemeral, serving as a gentle reminder of the preciousness of life.
  8. In addition to providing an external focus, sound can create a psychological screen (white noise) that serves the restoration process. A water feature can provide this pleasing and soothing sound. Care should be taken to place it in a wind-protected location where people can sit nearby, and where airconditioning or other irritating noises do not create too much competition.
  9. For the comfort of users, where offices or patient rooms border the garden, create a planting buffer of sufficient distance and depth so that people walking or sitting in the garden do not feel that they are intruding on the privacy of those indoors.
  10. Paths that meander allow for strolling and contemplation and complement more heavily used direct routes between access points. Where the space is large enough, pro- vide varying vistas, levels of shade, and textures of planting along these routes.
  11. Select paving surfaces that are smooth enough to accommodate wheelchairs and gurneys.
  12. In long-term facilities, arrange entrances to the garden and width of pathways so that volunteers or family members can easily bring a patient on a gurney or in a wheelchair out into the space.
  13. Electrical outlets allow for the garden to be used for hospital parties or other sponsored functions, extending the use to other people who may not usually come.
  14. Nighttime lighting maximizes the therapeutic benefit by allowing people to use the space safely after dark, or to look out at the garden from indoors.
  15. Seating arranged for social interaction (right angled or centripetal benches, or mov- able chairs) near to the entrance into the garden adds convenience, as this area will likely be used for quick smoking breaks by staff who know each other.
  16. Seating partly enclosed by planting, or at the perimeter of an open space, provides a degree of privacy for those wanting to be alone, or who want to observe from a distance.
  17. Fixed seating with backs for sitting in comfort is especially important for garden users who may be physically weak.
  18. If bench type seating is provided, select a material that is appealing to the touch (i.e., wood) and a size (4–6 feet) such that one or two people can “claim” the space. The image might be of a garden bench, rather than a park or bus stop bench.
  19. Increase the seating options available with movable seating so that users can meet their own particular needs. These chairs can be moved, selecting the degree of sun and shade, as well as determining the size of the seating cluster.
  20. Benches, platform seating, or planter edge seating with something to support the back allows people to sit with their feet up — or they can lie down to take a nap or sunbathe, as was frequently observed.
  21. Tables with movable chairs or benches provide for users who want to hold a meeting or eat, especially where the space is adjacent to the cafeteria.
  22. Adjustable umbrellas allow people to control the amount of sun or shade, so important to those who feel unwell or are taking certain medications.
  23. Wind shelters, heat-reflecting surfaces — or alternatively, shade-producing arbors — and other structures and planting help to mitigate the climate, and extend the use of the gar- den into several seasons.
  24. Where there is a view, make sure that some seating faces that direction to facilitate psychological movement out of the space. If the exterior space is a roof garden or terrace, the edge rail, balustrade, or planter should be sufficiently low or transparent so that people seated can take in the view.
  25. Where there is not a ready made view, a sense of mystery and movement can be created by designing smaller scale glimpses and intriguing focal points within the garden, to draw the users’ attention and, sometimes, facilitate a change in perspective.
  26. Providing one or more eye-catching and unique features by which people will identify a garden — such as a sculpture, wind chimes, an aviary, a fish pond — serves to anchor memories of the garden and the restoration achieved there.
Cleveland Clinic Children’s, University Hospital’s Rainbow Babies and Children’s Hospital and Akron Children’s Hospital ranked among the top 50 health centers in several categories in the U.S. News & World Report’s 2017-2018 Best Children’s Hospitals Rankings.


Marcus, C. C., & Barnes, M. (1995). Gardens in healthcare facilities: Uses, therapeutic benefits, and design recommendations. Concord, CA: Center for Health Design.ISO 690