1. Introduction
Population ageing is a global phenomenon that poses new challenges
to geriatric practice and to all professionals working in related fields.
Rising life expectancy is accompanied by a higher prevalence of
chronic diseases, dementias and social isolation-factors that profoundly affect
the emotional and cognitive well-being of older adults.
In this context, there is a need for
non-pharmacological, humanizing strategies capable of promoting relational
health, affection and dignity in care
1.1. Older people in Portugal over the last decade: A portrait of ageing in transition
Over the past ten years, the situation of older adults in Portugal
has worsened across several dimensions: demographic ageing, increased frailty,
growth in “social admissions” and worrying signs of abandonment.
The proportion of people aged 65+ has remained very high (c. 24% in 2024), and the ageing
index has risen
steadily, reflecting an
upward median age.
In terms of health and functional status, national and European studies
document substantial prevalences of pre-frailty and frailty
among Portuguese older adults-estimates indicate around 15% living with frailty and much higher percentages in
pre-frailty-with direct impacts on dependency, fall risk and the need for
continuing care. These conditions render older adults more vulnerable to
prolonged hospitalizations and transitions to
long-term social care. In parallel, social admissions-patients who remain
hospitalized despite being clinically fit for discharge due to lack of adequate social
responses-have grown markedly: recent reports identify
more than 2,300 recorded cases and an ~8% increase in beds occupied
by social admissions within a single year, overburdening the National Health Service
and exposing gaps in residential facilities and the long-term care network.
Family abandonment and neglect, documented in sociological studies
and academic reports, emerge as compounding factors- stemming from households’
economic fragility, insufficient formal support networks and still-fragmented
public policies. Researchers advocate integrated interventions: strengthening
primary care, expanding home-based services and increasing
residential/step-down solutions to reduce inappropriate admissions and prevent
isolation and abandonment.
In sum, over the last decade Portugal
has faced a confluence
of intense ageing, higher frailty
prevalence and growth in social admissions-demanding cross-sector
policies, targeted financing and continuous evaluation based on epidemiological
and social indicators.
1.2. Palhaços d’Opital, the association that humanizes with smiles
A mission with heart.
Palhaços d’Opital (PdO) is a Portuguese non-profit association, founded on 12 February 2013, that works exclusively
with hospitalized adults and older
people. The organization was a European pioneer in creating the concept of Elder
Clowning, adapting the hospital
clown figure to the specific
needs of adults- and particularly older adults.
The Association delivers its mission to adults and older people in
hospital settings through regular visits to public hospitals, implemented by
professionals with specific training (clowns, musicians, actors, etc.).
With more than 1,580 visits conducted and over 7,780 hours spent in hospital environments, Palhaços d’Opital’s work constitutes an artistic intervention model with measurable impact on the emotional, social
and physiological health
of older adults.
1.3. The story behind the red nose
Palhaços d’Opital arose from co-founder Jorge Rosado’s dream of
becoming a Clown Doctor.
Isabel Rosado, the other co-founder and current CEO, was a primary-school teacher for 25 years.
With no prior experience in business or the third sector, she embraced this
mission, and together they recognized that hospitals are about far more than children. Children are the focus of most healthcare clown organizations worldwide,
yet older age groups are those most in need of intervention-and where the
greatest impact can be achieved.
Palhaços d’Opital’s hospital-based intervention seeks to act as a tool for improving health
conditions, reducing stress and positively shifting
mood. In doing so, it contributes to the humanization of the hospital
environment, valuing and dignifying older people.
Palhaços d’Opital innovatively leverages humor and artistic
performances to promote well-being, which has led to multiple scientific case studies validating the relevance of its intervention.
With the premise of bringing positivity to critical
environments-with lightness and joy-Palhaços d’Opital’s intervention aims to
create moments of abstraction from pain/ illness, acting through laughter,
humor, joy, music and artistic performances.
“Assuming art as a form of therapeutic intervention, we seek to have a positive impact on the mood and emotional
state of those who are hospitalized, in treatment or awaiting consultation, as
well as their companions-without forgetting healthcare professionals. These artistic interventions aim to humanize the hospital space
where adults/seniors find themselves, valuing and dignifying older people, thereby
providing an environment more conducive to healthier and faster recovery.” - Jorge
Rosado Palhaços d’Opital currently has an artistic team of 13
professionals, working regularly across 10 partner hospitals: IPO Coimbra,
ULS Santa Maria,
ULS Amadora-Sintra, ULS Matosinhos, ULS São João, ULS Santo António,
IPO Porto and IPO Lisboa.
2. Mission and Principles of Intervention
Palhaços d’Opital’s mission is to “humanize the hospital environment and the ageing process through art, humor, music,
joy and affection.”
Professional artists-known as “Palhaços d’Opital”-are trained in
theatre, music, improvisation and hospital clowning, and receive specific
training in geriatrics, dementias, palliative and end-of-life care, hygiene and
hospital ethics, etc.
Each visit is structured along three axes:
• Individualized empathic relationship, respecting the older person’s cognitive, emotional and physical state.
• Artistic co-creation-use of humor, singing, narrative and artistic dynamics to restore feelings of happy memories, belonging and identity.
• Interdisciplinary integration with clinical teams, ensuring alignment with therapeutic plans and medical routines.
The intervention model is based on fixed artistic duos that visit
the same services weekly, fostering continuity and trust- critical factors for
the senior population.
3. Scientific rationale
Elder clowning is now recognized as an emerging psychosocial and artistic intervention in gerontology. Studies conducted in Canada, Brazil, Portugal and Israel
document consistent benefits
in three main domains:
Palhaços d’Opital currently operates in 10 partner health
institutions/hospitals and has worked continuously since 12 February 2013.
• 4,000+ older adults regularly supported;
• 80% of healthcare professionals report an improved work environment and relationships with patients;
• 75% of family members report increased communication and vitality of their loved ones after visits;
• Internal evaluations show reductions in self-reported anxiety and sadness among hospitalized patients.
The impact also extends to the clinical community: PdO training in “Empathy, Humor and Communication in Geriatrics” has been incorporated into hospital humanization programs across several Portuguese units.
5. Relevance for Indian Gerontology
India faces a rapid population-ageing process-by 2050, more than 320 million people are expected to be aged 60+. In many contexts, elder care is shared among families, communities and institutions with limited resources.
In this scenario, the PdO model offers a replicable, culturally adaptable instrument for humanizing geriatric care, with three strategic components:
• Intercultural training for artists and healthcare professionals, combining traditional Indian arts (music, kathakali, mime, bhava) with principles of therapeutic cloning.
• Low-cost emotional intervention, with measurable psychological impact and no requirement for sophisticated technology.
• Promotion of intergenerational dialogue, valuing elders’ wisdom and life stories, aligned with Indian cultural values of respect for ancestry.
Implementing PdO-inspired pilot programs in Indian long- term care institutions could strengthen policies for active ageing and compassionate care.
6. Research Perspectives
We propose collaborative Luso-Indian studies to assess:
• Effects of elder clowning on mood, loneliness and agitation indicators;
• Physiological changes (blood pressure, salivary cortisol, heart-rate variability);
• Caregivers’ and healthcare professionals’ perceptions of institutional humanization.
The collection of quantitative and qualitative data will help consolidate scientific evidence and contribute to international guidelines on humanizing geriatrics.
7. Conclusion
Palhaços d’Opital’s experience demonstrates that humor, affection and artistic presence are clinically relevant instruments with substantial social and therapeutic value.
In a rapidly ageing world, interventions such as elder clowning are not merely complementary: they are essential to the dignity, well-being and emotional health of older adults.
Transposing this model to India, through cultural and scientific cooperation, may open a new chapter in global gerontology-one in which care and humor go hand in hand, to healthy effect.
7.1. Assessment via survey of hospitalized older adults
An improvement in well-being following Palhaços d’Opital professionals’ performances was perceived by 81.7% of surveyed older adults, with particular emphasis on mood change-feelings of lightness, joy, animation and an uplift in affective state.
Selected narratives from hospitalized seniors corroborate
these findings:
“They are a breath of fresh air. Beyond joy, they bring kindness, affection, love, and a word of comfort.”
“In many situations of frailty, they make days more pleasant and fun.”
“They make the day less heavy for those who are admitted, calmer, and they reduce the negative thoughts that a hospital visit or stay can provoke.”
Accordingly, a change in the affective state of seniors-clearly perceived by the individuals themselves-was concluded to result from Palhaços d’Opital’s artistic performances.
7.2. Impact assessment among professionals
The methodology also included a data-collection instrument for healthcare professionals present in services (across all hospital units where visits/artistic interventions occurred), with the aim of gauging perceived usefulness of the artistic visits and their relationship to hospitalized seniors’ mood.
• 80% agreement (“agree/strongly agree”) regarding the perceived impact of the Hospital Doctors (clown duos).
7.2.1.Specifically: seniors are less bored (83.6%); seniors feel more cheerful and in good spirits most of the time (83.6%); seniors become more communicative with one another and with their surroundings (85%). Respondents also perceived that seniors find it easier to relax (74.7%).
• 74.6% highlighted joy, animation, good spirits, relaxation and the humanization of services as differentiating factors of Palhaços d’Opital’s performances. Regarding perceived impact of the clown duos’ performances, 74.3% strong agreement was observed for the dimension referring to contribution to the humanization of hospital services.
7.3. Selected testimonies
“On the days they are in my department, there is a noticeable improvement in patients’ mood.”
“Problems and difficulties are faced and resolved with greater
lightness and serenity.”
“Their presence brings joy to a space associated with suffering.”
“When they are present, time pauses for a moment to forget the harsh reality of the hospital and allow a genuine smile/laughter to emerge-rare in daily life and so beneficial physically and mentally.”
“They are a breath of fresh air and joy that flood the ward, even if only for a few minutes; in those minutes, patients and professionals think about other things, smile and can detach from the complexity of the oncology context.”
7.4. Impact assessment from hospital administrations’ perspective
Hospital administrations emphasize the suitability and usefulness of the clown duos’ visits and their relationship with seniors’ mood. Over 80% of responses validate that the intervention changed seniors’ attitude towards being less bored, more cheerful and communicative, enabling a more positive affective state.
Professionals also recognize the importance of these interventions beyond the senior population, acknowledging their impact on professional practice and, consequently, their contribution to the humanization of healthcare services.
According to hospital administrations, Palhaços d’Opital’s intervention supports hospitals’ missions in delivering humanized care, representing part of their cultural capital and aligning with the Commitment to Hospital Humanization signed in 2019.
The intervention’s professional and specialized character is highlighted; the training underpinning the Hospital Doctors and their ability to tailor work to each person are evident. Their presence in hospitals is doubly important: they bring well-being to older patients and exert an indirect impact on healthcare professionals.
“There was great rapport between Palhaços d’Opital and the institution’s professionals. We realized that, during the time they were with us, the day became healthier-even if the shift was difficult or we had complex situations. There was always a space for joy.”
Given Palhaços d’Opital’s strong integration within hospital units, healthcare professionals perceive this as multidisciplinary work and view the project as another service provided by the hospital, complementing care delivery.
7.5. Impact assessment among companions and individuals in waiting areas
Statements recorded >70% agreement (“agree/strongly agree”), recognizing that Palhaços d’Opital’s duo made respondents’ hospital visits more pleasant (74.5% strongly agree) and that the hospital environment also benefits from these performances (85.1% strongly agree).
“Bless you for your work! You make all the difference in the visits you undertake. It is clear that everyone who is the target of your performance is touched by it and responds positively. You are that part of the treatment that comes in the form of joy.”
“People with enormous hearts who restore faith and the will to dream to those who suffer greatly in life and feel alone. Thank you.”
“You help us fulfil our mission. One of the values that forms part of the hospital’s cultural capital is the humanization of care and, with the playful intervention you carry out professionally and expertly, you are able to improve the mood of patients and of the hospital community. If I had to highlight one aspect, it is that you help us to fulfil our mission, which is to provide care.”
7.6. Conclusion
The suitability and usefulness of Palhaços d’Opital in hospital settings are recognized, with a perceived positive impact among healthcare professionals, contributions to service humanization, and improvements in patients’ mood.
Palhaços d’Opital’s intervention methodology is innovative and disruptive in being purpose-built to work with-and for-hospitalized seniors. It is implemented through visits by Palhaços d’Opital professionals, who bring joy, affection and good spirits to service users (with a core focus on seniors), formal and informal carers, families and healthcare professionals.
Accordingly, both professionals and hospital administrations recognize that artistic interventions affect the hospital environment and contribute to the humanization of healthcare services, validating Palhaços d’Opital’s art-based intervention. Perceiving the impact among healthcare professionals, they recognize its suitability and usefulness in hospital contexts, its contribution to humanization, and its positive effect on patients’ mood-thereby valuing and dignifying the role of the senior population.
Hospital administrations likewise validate that the clown duo’s intervention changes patients’ affective state, evidenced directly through observation of interactions and indirectly through healthcare professionals’ feedback.
The specific attention devoted to this population makes Palhaços d’Opital a distinctive project that excels in fulfilling its mission to dignify seniors.
8. Practical observations / knowledge gaps
Evidence is stronger in pediatrics; for older/adult populations, large randomized trials are still lacking.
9. References
1. Lopes-Júnior,
et al. Systematic review Conclusion: hospital clowns appear to improve
psychological well-being and emotional responses in hospitalized children;
consistent effects in reducing
anxiety and improving behavior during procedures, 2020.
2. Sliman, et al. Meta-analysis. Medical
clowning in hospitalized children Finding: meta-analysis of controlled studies
showed a significant reduction in
pre-operative anxiety and a trend towards reduced procedural pain in children attended
by medical clowns, 2023.
3. Sánchez,
et al. Anxiety, stress, pain and hormonal markers Results: clowning
interventions decreased indicators of stress, anxiety and pain in various
pediatric clinical situations; some studies also measured
hormonal changes (e.g.,
cortisol), 2024.
4. Shimshi-Barash, et al. Sleep and
length of stay Finding: clown interventions were associated with better sleep
quality and shorter hospital stays in children, suggesting effects that may
facilitate recovery, 2024.
5. Khoury, et al. study 2025 / recent
articles (Nature / Scientific Reports, 2025) Recent evidence indicates that
hospital clown programs may reduce length of stay in certain pediatric groups and
improve cooperation during treatments (controlled studies published 2024-2025).
6. Randomized
trials and digital interventions (e.g., JAMA Pediatrics, 2016) Example: an
application featuring “clown physicians” reduced pre-operative anxiety in
children in a randomized clinical trial-demonstrating that elements of humor/
distraction can be effective even when digitized. (jamanetwork. com)
7. Recent reviews
and meta-analyses. General
synthesis Multiple reviews/meta-analyses (2020–2024) converge on the
most consistent effect being on anxiety
and emotional stress;
effects on pain, biomarkers and length of stay are promising but
heterogeneous across studies, 2024.
8. Interventions in special contexts
(COVID-19, adult wards) Qualitative studies and reports show adaptation of clowning
to protective contexts (COVID) and point to emotional benefits in adults, but
quantitative evidence in older/adult populations remains limited and calls for
larger randomized trials.
9. Proposed mechanisms (theoretical reviews) Physiological hypotheses include stress reduction (lower cortisol), immune system activation via improved sleep and reduced anxiety, and increased adherence/cooperation during procedures-pathways that may translate humor into clinical gains. Various clinical studies have measured stress markers or indirect outcomes (sleep, length of stay).