# Use of Wearables in Frail Institutionalized Older Adults While Ambulating in Different Environments
## 4 Discussion  
We found that institutionalized older adults take less time, exhibit higher energy expenditure, and report greater perceived exertion when walking in the uncontrolled outdoor environment versus a controlled residential environment. Additionally, we observed higher energy expenditure in participants with overweight, and no significant differences were found in any of the three study variables when dividing the sample based on cognitive level. Studies such as that of [PERSON] et al. [34] show that frail older adults are slower in walking compared to those without frailty. By including the variable environment, previous research in the literature has studied walking in two different environments, specifically in a laboratory and in a free-living environment [35; 36; 37]. However, our study provides information on the influence of the environment in institutionalized frail older adults during walking, including results on variables such as energy expenditure and perceived exertion. The study by [PERSON] et al. [35] indicates that participants used a faster walking speed in the free-living environment compared to the laboratory environment. This result aligns with the findings of the present study, where participants took less time to complete the walk in the outdoor environment, as a higher walking speed corresponds to completing the activity in less time. However, [PERSON] et al. [36] reported a lower cadence during walking in the free-living environment, which corresponds to more time spent on the activity. These authors focused their studies on gait analysis in older adults living in the community, not institutionalized, while our findings center on the energy expenditure associated with walking and the perceived exertion of frail institutionalized older adults. [PERSON] et al. [38] did not find statistically significant differences in total daily energy expenditure between institutionalized and non-institutionalized older adults. The association between age and energy expenditure during walking has been demonstrated, with an increase in energy expenditure in this activity, particularly in those aged over 65 [39]. However, there are no studies that analyze differences in energy expenditure associated with walking in controlled indoor and uncontrolled outdoor environments in the older population. According to our findings, there are significant differences in energy expenditure between walking in the controlled and uncontrolled environments. [PERSON] [40] used MEC and the Barthel Index in institutionalized older adults and found that higher functional capacity leads to greater energy expenditure. In our research, we add additional information by analyzing and comparing energy expenditure in two distinct environments, where higher energy expenditure is observed when walking in the uncontrolled outdoor environment compared to the controlled residential environment. We believe that these data can provide important information to improve current residential physical activity programs by indicating whether walking activities should take place indoors or outdoors depending on the characteristics of the resident. \begin{table}
\begin{tabular}{l l l l l} \hline \hline  & \multicolumn{2}{l}{**Without**} & \multicolumn{2}{l}{**With**} & & \\  & **Cognitive** & **Cognitive** & **Cognitive** & **Cognitive** \\  & **Impairment** & **Impairment** & **Impairment** & **(n = 11)** & **(n = 19)** & **d-Cohen** \\ \hline Controlled residential environment & & & & & \\ Time (min) & 5.30 \(\pm\) 1.17 & 6.01 \(\pm\) 1.45 & 0.181 & 0.539 \\ MET & 1.76 \(\pm\) 0.95 & 1.22 \(\pm\) 0.36 & 0.111 & 0.752 \\ Borg Scale & 6.09 \(\pm\) 1.22 & 6.16 \(\pm\) 0.90 & 0.701 & 0.065 \\ Uncontrolled external environment & & & & \\ Time (min) & 4.81 \(\pm\) 0.61 & 5.13 \(\pm\) 1.33 & 0.713 & 0.309 \\ MET & 2.57 \(\pm\) 1.29 & 2.05 \(\pm\) 1.26 & 0.162 & 0.408 \\ Borg Scale & 6.91 \(\pm\) 1.30 & 7.00 \(\pm\) 1.00 & 0.688 & 0.08 \\ \hline \hline \end{tabular} Data expressed in M \(\pm\) SD; MET = energy expenditure.  
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