# Use of Wearables in Frail Institutionalized Older Adults While Ambulating in Different Environments
###### Abstract  
(1) Prolonged life expectancy often leads to declining health, reduced physical activity, and dependence, especially in institutionalized elderly. Frailty, obesity, limited functionality, and cognitive impairment are common. Physical activity programs for this demographic can increase weekly energy expenditure and improve frailty. Understanding differences in walking indoors versus outdoors is crucial for tailored programs. This study aimed to compare time, energy expenditure, and perceived exertion in institutionalized elderly walking indoors versus outdoors. It also explored how body mass index and cognitive levels affected these factors. (2) Employing a cross-sectional descriptive observational approach, the study gathered data on height, weight, accelerometers, the modified Borg Scale, the Timed Up and Go test, and the Lobo Cognitive Mini-Exam from a sample of 30 institutionalized older adults. (3) Walking outdoors leads to shorter walking times, higher energy expenditure, and increased perceived effort. Overweight individuals expend more energy in both settings, while cognitive impairment does not significantly impact walking preferences. (4) The study concludes that indoor walking is preferable for frail elderly due to lower perceived exertion, but outdoor walking is recommended for overweight individuals. Cognitive status does not influence the choice of walking environment. older adults; walking: nursing homes; environment; perceived exertion; energy expenditure 2024 1 of 65, energy expenditure related to physical activity decreases [9; 10], leading to poorer grip strength [11]. Related to energy expenditure is the resting metabolic rate, which can be used as an early identifier of functional health in the pre-trail and frail elderly population, where a higher resting metabolic rate is associated with a lower risk of health deterioration [12]. More active older adults tend to show better health indicators [9] and a higher prevention of potential issues related to low energy expenditure [11]. Some of these issues include metabolic syndrome, type 2 diabetes, obesity, and cardiovascular diseases [13]. In relation to physical activity and metabolic expenditure in older adults, the European Health Survey in Spain 2020 states that 68.35% of individuals aged 65 to 74 have overweight or obesity. This figure remains at 68.73% for adults between 75 and 84 years old, slightly decreasing to 58% in those aged 84 and above [3]. In institutional elderly individuals, there is a high prevalence of obesity accompanied by limitations in functional capacity and cognitive impairment [14], as a higher body mass index (BMI) could act as a risk factor for cognitive decline [15]. To prevent weight gain among the older population, engaging in physical activity is recommended and effective, as it increases total energy expenditure [16]. The participation of institutionalized older adults in physical activity programs leads to higher weekly energy expenditure [17] and contributes to improving frailty syndrome, gait parameters, cognitive function, and quality of life [18]. Between 60% and 80% of institutionalized older adults experience at least one fall per year, and they generally suffer two to three times more falls than healthy older adults without cognitive pathologies [19]. Maintenance and functional recovery programs in residential facilities include physical activity programs, where walking is a fundamental element, typically performed in a controlled indoor environment [17]. However, no research has been found that compares the benefits of walking in different environments, indoors or outdoors, in institutionalized older adults, nor the analysis of the impact of such activity based on individual or environmental characteristics. Therefore, the main objective of the study was to describe and evaluate differences in time, energy expenditure, and the perception of effort in institutionalized older adults while walking in a controlled residential environment and in an uncontrolled outdoor environment.