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Review

Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning

by
Amy E. Peden
1,2,
Danielle H. Taylor
2 and
Richard C. Franklin
2,*
1
School of Population Health, Faculty of Medicine and Health, University of New South Wales, Kensington, NSW 2052, Australia
2
College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2022, 19(14), 8863; https://doi.org/10.3390/ijerph19148863
Submission received: 23 June 2022 / Revised: 19 July 2022 / Accepted: 19 July 2022 / Published: 21 July 2022
Browse Figure
Versions Notes

Abstract

:
Medical conditions can increase drowning risk. No prior study has systematically reviewed the published evidence globally regarding medical conditions and drowning risk for adults. MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest) and SPORTDiscus databases were searched for original research published between 1 January 2005 and 31 October 2021 that reported adult (≥15 years) fatal or non-fatal drowning of all intents and pre-existing medical conditions. Conditions were grouped into the relevant International Classifications of Diseases (ICD) codes. Eighty-three studies were included (85.5% high-income countries; 38.6% East Asia and Pacific region; 75.9% evidence level III-3). Diseases of the nervous system (n = 32 studies; 38.6%), mental and behavioural conditions (n = 31; 37.3%) and diseases of the circulatory system (n = 25; 30.1%) were the most common categories of conditions. Epilepsy was found to increase the relative risk of drowning by 3.8 to 82 times, with suggested preventive approaches regarding supervised bathing or showering. Drowning is a common suicide method for those with schizophrenia, psychotic disorders and dementia. Review findings indicate people with pre-existing medical conditions drown, yet relatively few studies have documented the risk. There is a need for further population-level research to more accurately quantify drowning risk for pre-existing medical conditions in adults, as well as implementing and evaluating population-level attributable risk and prevention strategies.

1. Introduction

Drowning has been described as an underexplored threat to public health [1]. Drowning, the process of experiencing respiratory impairment due to immersion or submersion in liquid, has both fatal and non-fatal outcomes, with or without morbidity [2]. Drowning may also be unintentional, intentional or of undetermined intent. Unintentional drowning alone was estimated to claim the lives of 295,000 people around the world in 2017, with the true estimate likely to be significantly higher with the inclusion of transportation and disaster-related drowning [3]. Though less is known about drowning due to intentional self-harm [4,5], many countries also report high drowning rates due to suicide [6,7,8].
Chronic medical conditions are becoming more common [9]. This phenomenon effects low and high-income countries alike. Research on unintentional drowning risk among children has identified epilepsy [10,11] and autism spectrum disorder as conditions posing an increased risk of drowning [12,13,14]. Several studies have explored the role of chronic disease on drowning risk among older people—an age group of growing concern with respect to drowning due to an aging population [15,16]. Studies among the elderly population have highlighted the risk for drowning of conditions such as dementia, sarcopenia, epilepsy, cardiac conditions and depression [5,11,17,18,19,20]. However, little is known regarding the drowning risk associated with pre-existing medical conditions and the interventions recommended to reduce this risk.
To date, no study has systematically reviewed the literature to examine the role of pre-existing medical conditions on adult drowning risk. This review will address the following research questions concerning the link between pre-existing medical conditions, drowning and drowning risk:
  • Which pre-existing medical conditions have been reported in adult (aged 15 years and older) drowning cases?
  • Which pre-existing medical conditions does the literature suggest impact the risk of drowning?
  • In which population (s) do pre-existing medical conditions increase drowning risk and burden?
  • What drowning reduction strategies are recommended in the literature?

2. Materials and Methods

A systematic review of peer-reviewed literature was undertaken to identify and critically analyse studies reporting drowning and chronic medical conditions in adults (aged 15 years and older) and was prospectively registered with PROSPERO (#CRD42020190605). The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [21]. From the search results, the PRISMA statement was used to identify, screen and determine eligibility for the included studies.
Peer-reviewed literature published in English between 1 January 2005 and 31 October 2021 was identified from searches of MEDLINE (OVID), PubMed, EMBASE, Scopus, PscyINFO (ProQuest) and SPORTDiscus databases. Search terms were intentionally broad, and no qualification of methodology or publication type was applied in the first search to capture all relevant article sets. Search terms included “drown*”, “adult”, “medical”, “disease” and various medical conditions. Where possible, terms and medical conditions were mapped to MESH terms. The Boolean search strings utilised for this study are described in Appendix A.
Literature was limited to a publication date of 2005, as this was the year the current drowning definition was established [2]. Studies of human drowning and chronic medical conditions were included regardless of outcome (fatal or non-fatal) and intent (unintentional, intentional self-harm, undetermined intent). Non-fatal drowning was defined in line with the Non-Fatal Drowning Categorisation Framework (NDCF) [22]. The full inclusion and exclusion criteria for the study are displayed in Table 1. Studies were included where data could be extracted for pre-existing medical conditions for people aged 15 years and older. Medical conditions were included if there was a history of the condition for the person who drowned, even if the condition was not indicated at autopsy. Conditions noted at autopsy but unknown at the time of the drowning incident were also included. Studies were excluded if they only reported acute conditions (e.g., a broken bone during the drowning incident). Case reports were included if they contained data for six or more drowning cases, regardless of the presence of a pre-existing medical condition. (Table 1).
Using Covidence literature screening software, the independent dual screening of title and abstract was undertaken, with conflicts resolved via consensus between the two reviewers. The process was repeated for the full-text review. Data were extracted using a custom-built Microsoft Excel spreadsheet. Data extracted included age group and number of participants, number of drowning incidents including by intent and outcome, study type, name of medical condition(s), number, proportion and/or rate of those who drowned with medical condition and statistical measure of risk (i.e., Chi-square tests of independence, relative risk, odds ratio). Medical conditions were identified by extracting key medical findings (i.e., medical condition, pathophysiology findings) presented in the literature. Specific medical conditions were coded to the relevant category within the International Classification of Diseases (ICD) 10 category [23]. The categories and examples of conditions coded to each category taken from included studies are shown in Table 2. For the top three most common groups of conditions, the specific conditions within the groupings were further categorised as depicted in Table 2 [24,25]. Where studies did not report on a specific medical condition, these were coded to a grouping called “all pre-existing medical conditions”.
Risk factors were defined if statistical tests identified a significant link between the medical condition and risk of drowning or drowning outcome (i.e., Chi-square tests of significance, odds ratio, relative risk). Prevention strategies were extracted as free text if proposed, implemented and/or evaluated specific to drowning. Prevention strategies were coded as primary, secondary or tertiary prevention [26] and against the corresponding level within the Hierarchy of Control [27]. Quality of evidence was also assessed using the National Health and Medical Research Council (Australia) Levels of Evidence [28]. Levels of evidence range from Level I (a systematic review of Level II studies (randomised controlled trial)) to Level IV (case studies with either post-test or pre-test/post-test outcomes). Region and income levels of countries represented in included studies were assessed using the World Bank open data country profiles [29].

3. Results

Initial searches identified 5762 studies. After the removal of 1834 duplicates, a total of 3928 studies were screened at the title and abstract stage. After the removal of studies not meeting the inclusion criteria, 738 full-text studies were assessed for eligibility. Following a full text review, 83 studies were included for data extraction (Figure 1).
Included studies predominately reported data from high-income countries (n = 71; 85.5%). The largest numbers of included studies were from the World Bank region groupings East Asia and the Pacific (n = 32; 38.6%) and Europe and Central Asia (n = 28; 33.7%). The majority of the included studies were assessed at a level of evidence of III-3 (n = 63; 75.9%). There were 48 studies (57.8%) that reported unintentional drowning, and 79 (95.2%) reporting fatal drowning. The study characteristics of the full list of included studies can be found in Appendix B.
With respect to grouped medical conditions, diseases of the nervous system [7,11,19,20,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57] and mental and behavioural conditions [7,37,42,43,54,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82] were the most commonly reported categories of medical conditions in drowning, identified in 32 studies (38.6%) and 31 studies (37.3%), respectively. This was followed by diseases of the circulatory system (n = 25 studies; 30.1% of all included studies) [19,43,46,49,53,54,55,57,63,76,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98] (Table 3).
There were 13 studies that reported all pre-existing medical conditions [7,43,49,53,63,69,98,103,104,105,106,107,108]. The proportion of drowning involving pre-existing medical conditions ranged from 2.8% with chronic illness among fatal land motor vehicle drownings in Finland [106] to 24.6% of elderly (defined as 65 years and over) drowning patients in South Korea (fatal and non-fatal) reporting chronic illness (such as diabetes, hypertension and hepatitis) [69]. In the South Korean study, a significantly higher (p < 0.001) of elderly patients had chronic disease (24.6%) compared with the rest of the adult population who drowned (3.3%)[69]. A total population study of unintentional drowning fatalities in Canada identified that 67.3% of all adults 65+ years reported one or more accompanying chronic conditions [98]. Pre-exiting medical conditions were also prevalent in a study of intentional drowning death in Australia, found in 83.1% of deaths [7].
Seizure disorders (including epilepsy) were the most commonly reported condition within the diseases of the nervous system category, reported in 23 studies [11,19,20,30,32,33,34,35,37,38,39,40,43,44,45,46,47,49,52,53,54,55,56]. Epilepsy was found to occur in 11% of sudden deaths in hot bathtubs in Japan [20] and 9.6% of adult unintentional fatal drownings in Bangladesh [37]. Among those with epilepsy, drowning accounted for 83.3% of accidental injury deaths in Bangladesh [44] yet just 0.05% of seizure-related fatal unintentional injuries in Thailand [38] and 0.4% of hospitalised epilepsy deaths in the USA [39].
Almost half (49.1%) of all people in Portugal and the United Kingdom (UK) surveyed with Parkinson’s Disease reported having experienced a non-fatal drowning [48]. Drowning deaths of people with dementia who die after going missing or wandering span from 11.3% to 42.1% [36,51] (Table 4).
Within the mental and behavioural conditions category, psychotic disorders (n = 15 studies) and mood disorders (n = 13 studies) were the two most commonly reported types of conditions implicated in cases of drowning. Drowning accounted for 9% of suicidal deaths in patients with schizophrenia in Taiwan [74]. Among those with psychotic disorders, drowning deaths varied from a high of 20.9% among people with personality disorders in Sweden [60] to a low of 1.3% of intentional drowning deaths in Australia [7]. Forty percent of psychiatric patients who died by suicide in South Korea drowned with psychotic disorders [75]. Psychotic disorders were present in 27.2% of patients who died from intentional drowning within one year of contact with mental health services in the UK [65].
Mood disorders (including bipolar and depression) were present in 61.3% of drowning deaths (both intentional and unintentional) in the Madurai region of India [79] and in 45.0% of intentional fatal drowning among psychiatric patients who suicided in South Korea [75]. A further eight studies reported substance abuse disorders. It should be noted that substance use disorders were present in 75.3% of suicidal drowning deaths in Australia [64] and 15.6% of drowning deaths in France [76] (Table 5).
Heart arrythmias (or related conditions) were the most commonly reported condition within the diseases of the circulatory system category, reported in eight studies [19,63,83,84,86,91,95,96]. Heart arrythmias were present in 22.9% of “unexplained” drowning deaths referred for a cardiac channel molecular autopsy in the USA [91] and 22.2% of diving-related drowning fatalities in Australia [95]. Among older people, heart arrythmias were present in 21.7% of bathtub drownings among people aged 65+ years in Canada [63] and 15.6% of the same cohort in Australia [19].
Ischaemic heart disease was identified in five included studies [53,55,85,89,90]. Two studies were from Greece, finding that ischaemic heart disease was present in 87.9% [85] and 51.8% of drowning deaths, respectively [89]. Two other studies reporting bath-related deaths found that ischaemic heart disease was present in 34.2% of bath-related deaths in Japan [53] and 73.7% in South Korea [55].
Among other circulatory system conditions, hypertensive heart disease was present in 66.7% of drowning deaths among those competing in triathlons in the USA [83,84], and atherosclerosis was found in 20% of those who drowned with a pre-existing medical condition in Greece [85] (Table 6).
Table
Table 5. Studies reporting conditions within the mental and behavioural conditions category.
Table 5. Studies reporting conditions within the mental and behavioural conditions category.
ConditionReferenceCountryStudy PopulationAge GroupIntentOutcome% Who Drowned% Who Drowned with Med Conditions% Who Drowned with Condition
Anxiety
disorder		Ahlm et al., 2015 [59]SwedenAll drowning deaths in Sweden16–85 yearsIF0.8%--
Cenderadewi et al., 2019 [7]AustraliaIntentional drowning deathsAll agesIF2.4%2.9%-
Fang et al., 2015 [61]ChinaIndividuals with psychiatric disorder who committed suicide by drowning10–89 yearsIF-1.9%-
Behavioural disorderBjorkenstam et al., 2016 [60]SwedenTotal population with personality disorders Sweden15–64 yearsIF-1.1%-
Ljusic et al., 2018 [70]SerbiaDeaths among those with mental disorders, somatic disorders or no registered disorder-IF14.1%100%
Cognitive
function		Bjorkenstam et al., 2016 [60]SwedenTotal population with personality disorders Sweden15–64 yearsIF-2.2%-
Fang et al., 2015 [61]ChinaIndividuals with psychiatric disorder who committed suicide by drowning10–89 yearsIF-9.7%-
Kim et al., 2021 [42]South KoreaDeaths of people with a disabilityAll agesUF-3.0%-
Mood disorderAaltonen et al., 2019 [58]FinlandAll suicide after first lifetime psychiatric hospitalisation for depression18+ yearsIF-7.4%-
Ahlm et al., 2015 [59]SwedenAll drowning deaths in Sweden16–85 yearsIF9.5%--
Bjorkenstam et al., 2016 [60]SwedenTotal population with personality disorders Sweden15–64 yearsIF-31.9%-
Cenderadewi et al., 2019 [7]AustraliaIntentional drowning deathsAll agesIF20.2%24.3%-
Fang et al., 2015 [61]ChinaIndividuals with psychiatric disorder who committed suicide by drowning10–89 yearsIF-64.5%-
Hunt et al., 2006 [65]UKSuicide with recent (within 1 year) contact with mental health services0–75+ yearsIF49.0%--
Lee et al., 2019 [69]South KoreaFatal drowning18+ yearsI,U, UndF18.7%--
Maity et al., 2020 [71]IndiaDrowning deaths0–70 yearsUndF4.9%--
Nishida et al., 2015 [73]JapanPatients diagnosed with early post stroke depression who died65–94 yearsIF70.8%--
Park et al., 2013 [75]South KoreaPsychiatric patients who suicide10+ yearsIF45.0%--
Runeson et al., 2010 [77]SwedenCompleted suicides among those treated for attempted suicide10+ yearsIF29.1%--
Schaffer et al., 2014 [78]CanadaSuicide in bipolar disorderAll agesIF--2.9%
Selveraj et al., 2020 [79]IndiaDrowning in Madurai RegionAll agesI,UF61.3%--
Personality
disorder		Bjorkenstam et al., 2016 [60]SwedenTotal population with personality disorders Sweden15–64 yearsIF-100.0%-
Hunt et al., 2006 [65]UKSuicide with recent (within 1 year) contact with mental health servicesAll agesIF3.7%--
Psychosexual disorderFang et al., 2015 [61]ChinaIndividuals with psychiatric disorder who committed suicide by drowning10–89 yearsIF-1.0%-
Psychotic
disorder		Ahlm et al., 2015 [59]SwedenAll drowning deaths in Sweden16–85 yearsIF4.2%--
Bjorkenstam et al., 2016 [60]SwedenTotal population with personality disorders Sweden15–64 yearsIF-20.9%-
Cenderadewi et al., 2019 [7]AustraliaIntentional drowning deathsAll agesIF1.1%1.3%-
Fang et al., 2015 [61]ChinaIndividuals with psychiatric disorder who committed suicide by drowning10–89 yearsIF-20.2%-
Flaig et al., 2013 [62]GermanyNon-natural death cases autopsied18–96 yearsIF9.0%--
Haines et al., 2010 [64]AustraliaCompleted suicides10–43 yearsIF80.6%--
Hunt et al., 2006 [65]UKSuicide with recent (within 1 year) contact with mental health servicesAll agesIF27.2%--
Kumar et al., 2018 [72]IndiaAttempted suicides in psychiatric consultation10–50 yearsINF-5%-
Lee et al., 2019 [69]South KoreaFatal drowning18+ yearsI,U, UndF7.1%--
Markarian et al., 2020 [43]FranceSelected patients admitted to ICU for a drowning-related incident40–74 yearsIF16.3%16.6%-
Pan et al., 2021 [74]TaiwanSuicide mortality in patients with schizophreniaAll agesIF--9.0%
Park et al., 2013 [75]South KoreaPsychiatric patients who suicide10+ yearsIF40.0%--
Runeson et al., 2010 [77]SwedenCompleted suicides among those treated for attempted suicide10+ yearsIF11.3%--
Stemberga et al., 2010 [80]CroatiaSuicidal drowning deaths23–86 yearsIF2.2%--
Stephenson et al., 2020 [81]AustraliaDrowning deaths in urban section of the River Torrens18–76 yearsI,UF32.4%--
Tellier et al., 2019 [54]FranceDrowning victims along Gironde surf beachesAll agesUF0.9%10.2%-
Substance abuse disorderAhlm et al., 2015 [59]SwedenAll drowning deaths in Sweden16–85 yearsIF1.4%--
Bjorkenstam et al., 2016 [60]SwedenTotal population with personality disorders Sweden15–64 yearsIF-13.2%-
Cenderadewi et al., 2019 [7]AustraliaIntentional drowning deathsAll agesIF24.9%29.9%-
Cenderadewi et al., 2019 [7]AustraliaIntentional drowning deathsAll agesIF11.1%13.4%-
Guay et al., 2019 [63]CanadaBathtub drownings people aged 65+65+ yearsUF3.3%--
Haines et al., 2020 [64]AustraliaCompleted suicides10–43 yearsIF75.3%--
Hunt et al., 2006 [65]UKSuicide with recent (within 1 year) contact with mental health servicesAll agesIF11.7%--
Reizine et al., 2021 [76]FranceDeath after non-fatal drowning in fresh and sea waterAll agesI,UF15.6%21.0%-
Williams et al., 2018 [82]USAUnintentional drowning episodes, resulting in death or injury among actively serving US armed forcesAll agesUF,NF7.0%--
Other disordersAhlm et al., 2015 [59]SwedenAll drowning deaths in Sweden16–85 yearsIF1.7%--
Park et al., 2013 [75]South KoreaPsychiatric patients who suicide10+ yearsIF15.0%--
Runeson et al., 2010 [77]SwedenCompleted suicides among those treated for attempted suicide10+ yearsIF14.7%--
All mental and behavioural disordersAhlm et al., 2015 [59]SwedenAll drowning deaths in Sweden16–85 yearsIF17.6%--
Cenderadewi et al., 2019 [7]AustraliaIntentional drowning deathsAll agesIF83.1%---
Fang et al., 2015 [61]ChinaIndividuals with psychiatric disorder who committed suicide by drowning10–89 yearsIF-1.0%-
Fang et al., 2015 [61]ChinaIndividuals with psychiatric disorder who committed suicide by drowning10–89 yearsIF-2.0%-
Guay et al., 2019 [63]CanadaBathtub drownings people aged 65+65+ yearsUF9.8%--
Hossain e al, 2017 [37]BangladeshAdult drowning18+ yearsUF9.9%--
Kielty et al., 2015 [66]IrelandIndividuals who died by probable suicide18+ yearsIF23.1%--
Kim et al., 2021 [42]South KoreaDeaths of people with a disabilityAll agesUF-7.0 *-
Koo et al., 2021 [67]AustraliaData from the Queensland Suicide
Register		65+ yearsIF44.6%--
Lawes et al., 2021 [68]AustraliaSuicidal deaths along the Australian coast18+ yearsIF59.8%--
Reizine et al., 2021 [76]FranceDeath after non-fatal drowning in fresh and sea waterAll agesI,UF26.7%36.0%-
Stemberga et al., 2010 [80]CroatiaSuicidal drowning deaths23–86 yearsIF13.4%--
Abbreviations: F = Fatal; I = Intentional; NF = Non-Fatal; OHCA = Out of Hospital Cardiac Arrest; U = Unintentional; UK = United Kingdom; Und = Undetermined; USA = United States of America; * represents crude mortality rate not proportion.
There were 10 risk factors identified from the literature. These included increasing age, being at home, living near water, freshwater, medical conditions, medication (not on correct dose), sex (depending on medical condition), time of day and inpatient vs outpatient treatment (Table 7).
For epilepsy, there is an increase in the risk of drowning from between 3.8 times in the USA [39] to 82 times in China [47]. Specific to epilepsy and drowning, those with epilepsy in a study from the USA were found to be more likely to drown at home than in hospital or at a health care facility [31]; in rural China, those with epilepsy were found to have greater drowning risk if they resided in waterside areas than those living in the mountains [35], to have had epilepsy for a shorter period than those who survived [47] and to have a lower dosage of phenobarbital recorded at time of last follow up than those who survived [47].
By sex, females with personality disorders [60] and schizophrenia [74] were found to be at increased risk of suicidal drowning when compared to males; however, males were found to be at increased risk of dying from drowning with epilepsy [47]. Older age was found to be a risk factor for drowning with pre-existing medical conditions in studies of disability in South Korea (those aged 80+ years) [42], among coastal drowning fatalities in Australia [105] and for elderly patients with diabetes, hypertension and hepatitis in South Korea [69] (Table 7).
There were a total of 17 studies that discussed 26 unique strategies for preventing drowning related to pre-existing medical conditions [7,11,19,31,34,41,44,47,48,53,57,59,68,77,89,91,96]. The majority of strategies were administrative in nature when aligned to the Hierarchy of Control (n = 24; 92.3%) and all were proposed, as opposed to implemented and/or evaluated. Strategies were commonly educational in nature (n = 12 recommendations; 48.0% of all recommendations), followed by testing (n = 6; 24.0%), treatment (n = 3; 12.0%) and policy (n = 3; 12.0%) (Table 8).
Table
Table 7. Risk factors related to pre-existing medical conditions and drowning.
Table 7. Risk factors related to pre-existing medical conditions and drowning.
Risk FactorMedical Condition Note Reference
AgeDisability
Precipitating medical factors
Chronic disease		Age related risk for drowning increased as people age, for example for precipitating medical factors younger (15–34 year) males were 3.7 times less likely to drown *. [42]
[105]
[69]
Location—homeEpilepsyPeople with epilepsy/seizures were more likely to drown at home (RR = 2.35, 95% CI = 1.9–3.0, p < 0.001) than people without epilepsy/seizures.[31]
Location—waterside areasEpilepsyLiving near water increased the risk compared to those living in the mountains (Hazard Ratio 3.9, 95% CI 1.7–9.2, p = 0.002). [35]
Location—FreshwaterMental and
behavioural condition		When comparing baseline characteristics of the patients according to the salinity of the water, freshwater drowning patients were younger and suffered more often from psychiatric comorbidities (47.9 vs. 19.1%; p < 0.001).[76]
Medical
condition		Cardiac disease
Cardiomegaly
Cardiomyopathy *
Chronic conditions
Circulatory system
Dementia
Epilepsy
Mental and behavioural condition
Mental and Psychotic disorder
Schizophrenia		There were 10 medical conditions or groups of conditions that were identified as increasing the risk of drowning. Cardiac disease was found in 14% of all accidental drownings but in none (0%) in the suicide group p < 0.05. Cardiomegaly (p < 0.05) was higher among those who drowned compared to other causes of sudden or violent death. Drowning cases had significantly lower odds of presenting with cardiomyopathy (p < 0.001) than other causes of sudden or violent death. Those with chronic diseases had an OR of 15.1 compared with those who drowned without pre-existing disease. Significantly higher association of CT genotype/allele in drowned people (0.545) than controls (0.279) p = 0.008. Drowning was OR 1.55 (95%CI: 0.90–2.69) times more likely among those with dementia than healthy individuals as a suicide method. People with epilepsy drown at a rate between 6.7–82 times greater than the general population, depending on location and age group. Patients with alcoholism more likely to die from drowning. For example, service members with any history of alcohol-related disorder were nearly twice that of those without any history of alcohol-related disorder. Compared with the general population, people with psychotic disorders were 3.28 times (95%CI: 1.16–9.26) more likely to suicide by drowning. Compared to poisoning, psychotic disorder males with a Hazard Ratio 6.2 (95%CI: 3.3 to 11.6) and females with a Hazard Ratio 9.7 (95%CI: 5.3 to 17.8) were more likely to successfully suicide by drowning. Patients diagnosed as having schizophrenia were more likely to commit suicide through drowning than the general population (odds ratio (OR) = 1.48, 95% CI = 1.27–1.73, p < 0.001).[97]
[85]
[85]
[103]
[93]
[50]
[11]
[30]
[33]
[35]
[39]
[44]
[47]
[47]
[76]
[82]
[75]
[77]
[74]
MedicationEpilepsyThe dosage of phenobarbital recorded at the time of last follow-up was lower (p < 0.001) in the group who drowned than in those who survived.[47]
Sex—femalePersonality disorders
Schizophrenia		Women diagnosed with a PD had the highest SMR for drowning. Compared with schizophrenic men, schizophrenic women were more likely to suicide through drowning (23.8 cases in every 100,000 people; p < 0.001).[60]
[74]
Sex—maleEpilepsyMales with epilepsy were more likely to drown than females with epilepsy (p = 0.017). [47]
TimePsychotic disordersPatients were more likely to use suicide methods other than hanging (e.g., OR = 6.7 for jumping, 5.3 for drowning and 2.7 for self-poisoning) between midnight and dawn.[75]
TreatmentPsychotic disordersCompared with outpatients, patients who had received inpatient treatment were more likely to use drowning (OR = 3.46; 95%CI: 1.30–9.22; p = 0.013) than hanging.[75]
Abbreviations: COD= cause of death; CI = confidence interval; OR = odds ratio; PD = personality disorder; RR = Relative Risk; SMR = standardised mortality rate. * denotes lower drowning risk.

4. Discussion

As the global population ages, the prevalence of comorbidities grows [109]. This systematic literature review shows that drowning occurs in people with pre-existing medical conditions, and that people with pre-existing medical conditions appear to be over-represented in drowning statistics. It also identified several conditions where drowning risk is heightened. Epilepsy was found to increase the relative risk of drowning by between 3.8 [39] and 82 times [47]. Risk factors for drowning in epilepsy included being of male sex [47], drowning at home [31], lower dosage of phenobarbital [47] (although it must be noted this is not a commonly used medication for seizure control/management in middle and high income country medical systems) and having a shorter duration of epilepsy [47]. Aside from seizures, other nervous system conditions, including dementia and Parkinson’s Disease, were also identified. Drowning is both a leading cause of death among those with dementia who die while wandering [36] and a common suicide method for those with dementia [50]. Parkinson’s Disease was reported to impact swimming ability leading to non-fatal drowning [48].
Mental and behavioural conditions was the second most commonly explored category of condition within the included literature. The included literature identified drowning as a popular suicide method for those with schizophrenia [74], psychotic disorders [77] and dementia [50]. Comprehensive psychiatric assessment and management and education in alcohol and substance misuse were recommended as education-based primary prevention strategies for intentional drowning involving mental and behavioural disorders, as well as bystander rescue and CPR training as secondary and tertiary measures [7]. Suicide response training for lifeguard and lifesavers has also been proposed, but not yet implemented or evaluated [68].
Diseases of the circulatory system were highlighted in 30% of included studies. Given ischaemic heart disease remains a leading cause of mortality globally [110], it is unsurprising to see cardiac conditions well represented within the drowning literature. Similarly, physical exercise such as swimming can temporarily increase the risk of aggravating cardiovascular conditions [85]. This is an important challenge, as aquatic exercise can be an effective and low-impact form of exercise, thus improving health and fitness [111]. The prevalence of unknown cardiac disease or cardiac conductivity issues during autopsy was also highlighted [63,83,86,91].
Diseases of the nervous system were also highlighted in the literature. Nervous systems disorders are wide-ranging, and this was reflected in the literature. The conditions that were highlighted appear to reflect those relating to the central nervous system and those that propagate immobility. Although aquatic exercise is often promoted to individuals with these conditions due to the non-weight bearing nature of the exercise, the risk of drowning must be considered. Levels of consciousness and mobility both pose a risk in drowning.
With this exploration of drowning and medical conditions, it was difficult to determine if there was an increased rate of drowning. For future studies, we propose that the studies include the total number of drowning deaths, the total number of people in the population, the population rate of the condition being studied and a relative risk (or similar) for drowning. This would allow future reviews to clearly be able to show the rate of drowning and the rate of drowning in the condition being explored, thus enabling a relative risk to be calculated.
One of the most common drowning prevention recommendations related to supervised bathing or the replacement of bathing with showering for those with diseases of the nervous system, such as seizure disorders [31]. Additionally, it was recommended that care givers of those with diseases of the circulatory system be aware of the drowning risks for those with such conditions, especially in the winter months [53]. For elderly adults with pre-existing medical conditions of any kind, showering with the use of an aid, such as a chair, was also recommended [19]. The majority of proposed drowning prevention encompassed primary drowning prevention strategies; however, many were administrative in nature, reflecting a low level of effectiveness on the hierarchy of control [27]. Additionally, all 25 unique drowning prevention recommendations were proposed only, identifying a knowledge gap regarding the efficacy of interventions based on implementation and evaluation.
Finally, with an aging population and increasing comorbidities comes an increased prescription medical rate, resulting in polypharmacy [112]. Multiple medications can contribute to drowning risk [113]; however, no study to date has examined the complex nature of polypharmacy, pre-existing medical conditions and adult drowning risk. This topic presents an opportunity for future research.
This study is the first to systematically explore the peer-reviewed literature to explore drowning and comorbidities and provides valuable information around conditions increasing drowning risk and research gaps. However, the findings of this study must be considered in light of some limitations. Within the included literature, we did not document if the person who drowned knew they had the particular condition or were treated appropriately for it. Only one included study reported medication levels as a risk factor, exploring phenobarbital levels among epileptics [47]. Secondly, the included studies are where drowning and a particular pre-existing medical condition co-occurred; there did not need to be, nor did we draw, a causal link between drowning and the condition in order for the study to be included in this review. Thirdly, where multiple pre-existing medical conditions are present, we did not examine the attributable drowning risk for individual conditions. All limitations also offer opportunities to strengthen the evidence base around medical conditions and drowning risk in the future.

5. Conclusions

Drowning occurs in people with existing medical conditions. This review has highlighted several pre-existing medical conditions that increase drowning risk; however, we also identified numerous research gaps. As we live longer and the proportion of the population with comorbidities increases, there is a need to better quantify the drowning risk associated with pre-existing medical conditions. Future research should include population level studies comparing disease prevalence in the general population to those who drown and better delineate the attributable risk for those with multiple medical conditions. In addition, there is a need for the implementation and evaluation of proposed strategies to reduce drowning burden and the risk associated with pre-existing medical conditions.

Author Contributions

Conceptualisation, D.H.T., R.C.F. and A.E.P.; methodology, D.H.T., A.E.P. and R.C.F.; data extraction, A.E.P. and D.H.T.; writing—original draft preparation, A.E.P.; writing—review and editing, A.E.P., D.H.T. and R.C.F. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

Appendix A

Table
Table A1. Databases and Search Terms Used.
Table A1. Databases and Search Terms Used.
Search
Number		Search Term
MEDLINE (Ovid)
1 exp Drowning/3
2exp Water Sports/
3exp *Immersion/
4lakes/ or exp “oceans and seas”/ or ponds/ or rivers/ or dams/
5bathing beaches/or swimming pools/
61 or 2 or 3 or 4 or 5
7exp Death/
8exp Mortality/
9exp Morbidity/
107 or 8 or 9
11exp Chronic Disease/
12exp Epilepsy/
13exp Diabetes Mellitus/
14exp Mental Disorders/
15exp respiratory tract infections/or exp neoplasms/or exp musculoskeletal diseases/or exp digestive system diseases/or exp stomatognathic diseases/ or exp respiratory tract diseases/or exp otorhinolaryngologic diseases/or exp nervous system diseases/or exp eye diseases/or exp male urogenital diseases/or exp “female urogenital diseases and pregnancy complications”/or exp cardiovascular diseases/or exp “hemic and lymphatic diseases”/or exp “congenital, hereditary, and neonatal diseases and abnormalities”/or exp “skin and connective tissue diseases”/or exp “nutritional and metabolic diseases”/or exp endocrine system diseases/or exp immune system diseases/or exp “disorders of environmental origin”/or exp occupational diseases/or exp chemically-induced disorders/or exp “wounds and injuries”/
1611 or 12 or 13 or 14 or 15
176 and 16
1810 and 17
19exp adult/
2018 and 19
21limit 20 to (english language and humans and yr = “2005–2021”)
PUBMED
((drown* OR submer*) AND (death* OR mortality OR morbidity)) AND ((“chronic disease*”) OR (“chronic illness*”) OR (epilep*) OR (seizure*) (arrest*) OR (cardiac*) OR (cardio*) OR (pulmon*) OR (asystole*) OR (heart*) OR (lung*) OR (diabet*) OR (respir*) OR (neoplasm*) OR (cancer*) OR (musculoskeletal*) OR (digest*) OR (stomatognathic*) OR (lymphat*) OR (vascul*) OR (congenital*) OR (hereditary*) OR (metabol*) OR (endocrin*) OR (immun*) OR (liver*) OR (arrythmia*) OR (“multiple sclerosis”) OR (motor*) OR (dementia*) OR (Alzheimer*) OR (parkinson*) OR (nervous*) OR (nerve*) OR (neuro*) OR (Amyotrophic Lateral Sclerosis*) OR (autism*) OR (addict*) OR (mental*) OR (psych*) OR (“medical condition*)) AND ((humans[Filter]) AND (english[Filter]) AND (alladult[Filter]) AND (2005:2020[pdat])) Filters: Humans, English, Adult: 19+ years
(((“drown*”[All Fields] OR “submer*”[All Fields]) AND ((“death*”[All Fields] OR (((“mortality”[MeSH Terms] OR “mortality”[All Fields]) OR “mortalities”[All Fields]) OR “mortality”[MeSH Subheading])) OR ((((((“epidemiology”[MeSH Subheading] OR “epidemiology”[All Fields]) OR “morbidity”[All Fields]) OR “morbidity”[MeSH Terms]) OR “morbid”[All Fields]) OR “morbidities”[All Fields]) OR “morbids”[All Fields]))) AND ((((((((((((((((((((((((((((((((((((((((“chronic disease*”[All Fields] OR “chronic illness*”[All Fields]) OR “epilep*”[All Fields]) OR “seizure*”[All Fields]) AND “arrest*”[All Fields]) OR “cardiac*”[All Fields]) OR “cardio*”[All Fields]) OR “pulmon*”[All Fields]) OR “asystole*”[All Fields]) OR “heart*”[All Fields]) OR “lung*”[All Fields]) OR “diabet*”[All Fields]) OR “respir*”[All Fields]) OR “neoplasm*”[All Fields]) OR “cancer*”[All Fields]) OR “musculoskeletal*”[All Fields]) OR “digest*”[All Fields]) OR “stomatognathic*”[All Fields]) OR “lymphat*”[All Fields]) OR “vascul*”[All Fields]) OR “congenital*”[All Fields]) OR “hereditary*”[All Fields]) OR “metabol*”[All Fields]) OR “endocrin*”[All Fields]) OR “immun*”[All Fields]) OR “liver*”[All Fields]) OR “arrythmia*”[All Fields]) OR “multiple sclerosis”[All Fields]) OR “motor*”[All Fields]) OR “dementia*”[All Fields]) OR “alzheimer*”[All Fields]) OR “parkinson*”[All Fields]) OR “nervous*”[All Fields]) OR “nerve*”[All Fields]) OR “neuro*”[All Fields]) OR (“Amyotrophic”[All Fields] AND (((((((((((((((((((“functional laterality”[MeSH Terms] OR (“functional”[All Fields] AND “laterality”[All Fields])) OR “functional laterality”[All Fields]) OR “laterality”[All Fields]) OR “lateral”[All Fields]) OR “lateralisation”[All Fields]) OR “lateralisations”[All Fields]) OR “lateralise”[All Fields]) OR “lateralised”[All Fields]) OR “lateralises”[All Fields]) OR “lateralising”[All Fields]) OR “lateralities”[All Fields]) OR “lateralization”[All Fields]) OR “lateralizations”[All Fields]) OR “lateralize”[All Fields]) OR “lateralized”[All Fields]) OR “lateralizes”[All Fields]) OR “lateralizing”[All Fields]) OR “laterally”[All Fields]) OR “laterals”[All Fields]) AND “sclerosis*”[All Fields])) OR “autism*”[All Fields]) OR “addict*”[All Fields]) OR “mental*”[All Fields]) OR “psych*”[All Fields]) OR (((((((((((((((((((“medic”[All Fields] OR “medical”[All Fields]) OR “medicalization”[MeSH Terms]) OR “medicalization”[All Fields]) OR “medicalizations”[All Fields]) OR “medicalize”[All Fields]) OR “medicalized”[All Fields]) OR “medicalizes”[All Fields]) OR “medicalizing”[All Fields]) OR “medically”[All Fields]) OR “medicals”[All Fields]) OR “medicated”[All Fields]) OR “medication s”[All Fields]) OR “medics”[All Fields]) OR “pharmaceutical preparations”[MeSH Terms]) OR (“pharmaceutical”[All Fields] AND “preparations”[All Fields])) OR “pharmaceutical preparations”[All Fields]) OR “medication”[All Fields]) OR “medications”[All Fields]) AND “condition*”[All Fields]))) AND (((“humans”[MeSH Terms] AND “english”[Language]) AND “adult”[MeSH Terms]) AND 2005/1/1:2021/10/31[Date-Publication])
SCOPUS
((TITLE-ABS-KEY (drown*) OR TITLE-ABS-KEY (submer*)) AND (TITLE-ABS-KEY (death*) OR TITLE-ABS-KEY (mortality*) OR TITLE-ABS-KEY (morbidity*))) AND (TITLE-ABS-KEY (“chronic disease*”) OR TITLE-ABS-KEY (“chronic illness*”) OR TITLE-ABS-KEY (epilep*) OR TITLE-ABS-KEY (seizure*) OR TITLE-ABS-KEY (arrest*) OR TITLE-ABS-KEY (cardiac*) OR TITLE-ABS-KEY (cardio*) OR TITLE-ABS-KEY (pulmon*) OR TITLE-ABS-KEY (asystole*) OR TITLE-ABS-KEY (heart*) OR TITLE-ABS-KEY (lung*) OR TITLE-ABS-KEY (diabet*) OR TITLE-ABS-KEY (respir*) OR TITLE-ABS-KEY (neoplasm*) OR TITLE-ABS-KEY (cancer*) OR TITLE-ABS-KEY (musculoskeletal*) OR TITLE-ABS-KEY (digest*) OR TITLE-ABS-KEY (stomatognathic*) OR TITLE-ABS-KEY (lymphat*) OR TITLE-ABS-KEY (vascul*) OR TITLE-ABS-KEY (congenital*) OR TITLE-ABS-KEY (hereditary*) OR TITLE-ABS-KEY (metabol*) OR TITLE-ABS-KEY (endocrin*) OR TITLE-ABS-KEY (immun*) OR TITLE-ABS-KEY (liver*) OR TITLE-ABS-KEY (arrythmia*) OR TITLE-ABS-KEY (“multiple sclerosis”) OR TITLE-ABS-KEY (motor*) OR TITLE-ABS-KEY (dementia*) OR TITLE-ABS-KEY (alzheimer*) OR TITLE-ABS-KEY (parkinson*) OR TITLE-ABS-KEY (nervous*) OR TITLE-ABS-KEY (nerve*) OR TITLE-ABS-KEY (neuro*) OR TITLE-ABS-KEY (amyotrophic AND lateral AND sclerosis*) OR TITLE-ABS-KEY (autism*) OR TITLE-ABS-KEY (addict*) OR TITLE-ABS-KEY (mental*) OR TITLE-ABS-KEY (psych*) OR TITLE-ABS-KEY (“medical condition*”)) AND TITLE-ABS-KEY (adult*) AND TITLE-ABS-KEY (human*) AND (LIMIT-TO (PUBYEAR, 2021) OR LIMIT-TO (PUBYEAR, 2020) OR LIMIT-TO (PUBYEAR, 2019) OR LIMIT-TO (PUBYEAR, 2018) OR LIMIT-TO (PUBYEAR, 2017) OR LIMIT-TO (PUBYEAR, 2016) OR LIMIT-TO (PUBYEAR, 2015) OR LIMIT-TO (PUBYEAR, 2014) OR LIMIT-TO (PUBYEAR, 2013) OR LIMIT-TO (PUBYEAR, 2012) OR LIMIT-TO (PUBYEAR, 2011) OR LIMIT-TO (PUBYEAR, 2010) OR LIMIT-TO (PUBYEAR, 2009) OR LIMIT-TO (PUBYEAR, 2008) OR LIMIT-TO (PUBYEAR, 2007) OR LIMIT-TO (PUBYEAR, 2006) OR LIMIT-TO (PUBYEAR, 2005)) AND (LIMIT-TO (EXACTKEYWORD, “Human”) OR LIMIT-TO (EXACTKEYWORD, “Adult”) OR LIMIT-TO (EXACTKEYWORD, “Humans”)) AND (LIMIT-TO (LANGUAGE, “English”))
PsycINFO (ProQuest)
(drown* OR submers*) AND (death* OR mortality OR morbidity) AND ((chronic disease*) OR (chronic illness*) OR (epilep*) OR (seizure*) (arrest*) OR (cardiac*) OR (cardio*) OR (pulmon*) OR (asystole*) OR (heart*) OR (lung*) OR (diabet*) OR (respir*) OR (neoplasm*) OR (cancer*) OR (musculoskeletal*) OR (digest*) OR (stomatognathic*) OR (lymphat*) OR (vascul*) OR (congenital*) OR (hereditary*) OR (metabol*) OR (endocrin*) OR (immun*) OR (liver*) OR (arrythmia*) OR (multiple sclerosis) OR (motor*) OR (dementia*) OR (Alzheimer*) OR (parkinson*) OR (nervous*) OR (nerve*) OR (neuro*) OR (Amyotrophic Lateral Sclerosis*) OR (autism*) OR (addict*) OR (mental*) OR (psych*))
Date: After 01 January 2005
Language
English
Age group
Adulthood (18 Yrs & Older)
Population
Human
SPORTSDiscus
(drown* OR submers* OR river* OR lake* OR shower* OR bath* OR dam* OR beach* OR pool* OR pond* OR ocean) AND (death* OR mortality OR morbidity) AND ((chronic disease*) OR (chronic illness*) OR (epilep*) OR (seizure*) (arrest*) OR (cardiac*) OR (cardio*) OR (pulmon*) OR (asystole*) OR (heart*) OR (lung*) OR (diabet*) OR (respir*) OR (neoplasm*) OR (cancer*) OR (musculoskeletal*) OR (digest*) OR (stomatognathic*) OR (lymphat*) OR (vascul*) OR (congenital*) OR (hereditary*) OR (metabol*) OR (endocrin*) OR (immun*) OR (liver*) OR (arrythmia*) OR (multiple sclerosis) OR (motor*) OR (dementia*) OR (Alzheimer*) OR (parkinson*) OR (nervous*) OR (nerve*) OR (neuro*) OR (Amyotrophic Lateral Sclerosis*) OR (autism*) OR (addict*) OR (mental*) OR (psych*))
Limiters—Published Date: 20050101–20211031; Peer Reviewed; Language: English
Expanders—Apply equivalent subjects
Search modes—Boolean/Phrase
EMBASE (Ovid)
1 exp Drowning/3
2exp Water Sports/
3exp *Immersion/
4lakes/or exp “oceans and seas”/or ponds/or rivers/or dams/
5bathing beaches/ or swimming pools/
61 or 2 or 3 or 4 or 5
7exp Death/
8exp Mortality/
9exp Morbidity/
107 or 8 or 9
11exp Chronic Disease/
12exp Epilepsy/
13exp Diabetes Mellitus/
14exp Mental Disorders/
15exp respiratory tract infections/or exp neoplasms/or exp musculoskeletal diseases/or exp digestive system diseases/or exp stomatognathic diseases/or exp respiratory tract diseases/or exp otorhinolaryngologic diseases/or exp nervous system diseases/or exp eye diseases/or exp male urogenital diseases/or exp “female urogenital diseases and pregnancy complications”/or exp cardiovascular diseases/or exp “hemic and lymphatic diseases”/or exp “congenital, hereditary, and neonatal diseases and abnormalities”/or exp “skin and connective tissue diseases”/or exp “nutritional and metabolic diseases”/or exp endocrine system diseases/or exp immune system diseases/or exp “disorders of environmental origin”/or exp occupational diseases/or exp chemically-induced disorders/or exp “wounds and injuries”/
1611 or 12 or 13 or 14 or 15
176 and 16
1810 and 17
19exp adult/
2018 and 19
21limit 20 to (english language and humans and yr = “2005–2021”)

Appendix B

Table
Table A2. Characteristics of Included Studies (n = 83).
Table A2. Characteristics of Included Studies (n = 83).
Reference Study Period Study CountyWorld Bank RegionIncome LevelEvidence LevelStudy PopulationAge Group Drowning OutcomeDrowning Intent
FNFUIUnd
Aaltonen et al., 2019 [58]1991–2011FinlandEurope and Central AsiaHICIVSuicide after first lifetime psychiatric hospitalisation for depression18+X X
Ahlm et al., 2015 [59]1992–2009SwedenEurope and Central AsiaHICIII-3Total population drowned in Sweden16–85 X X
Bain et al., 2018 [11]2014–2016CanadaNorth AmericaHICIII-3Epilepsy or seizure with suspicion of drowning12–68X X
Barooni et al., 2007 [30]2004CanadaNorth AmericaHICIII-3Epilepsy population deaths0–90X X
Bjorkenstam et al., 2016 [60]1987–2013SwedenEurope and Central AsiaHICIVPopulation with personality disorders15–64X X
Bowman et al., 2010 [31]1999–2005USANorth AmericaHICIII-3Patients with epilepsy 0–64 X XXX
Cenderadewi et al., 2019 [7]2006–2014AustraliaEast Asia and PacificHICIII-3All age intentional drowning deaths 0–75+X X
Chang et al., 2012 [33]1989–2008TaiwanEast Asia and PacificHICIII-3Deaths with epilepsy0–70+ X X
Chang et al., 2014 [32]1981–2010USANorth AmericaHICIII-3Mentions of epilepsy on death certificate0–65+ X X
Cihan et al., 2018 [34]2000–2016USANorth AmericaHICIII-3Epilepsy deaths in water20–73X X
Claesson et al., 2013 [97]2002–2010SwedenEurope and Central AsiaHICIII-3Autopsied drowning cases (Swedish National Board of Forensic Medicine)22–71X XXX
Clemens et al., 2016 [98]2008–2012CanadaNorth AmericaHICIII-3Drowning incidents in Canada15–65+X X
Ding et al., 2013 [35]2000–2004ChinaEast Asia and PacificUMICIII-3Diagnosis of epilepsy at primary health centre10–69 X XXX
Fang et al., 2015 [61]2010–2014ChinaEast Asia and PacificUMICIII-3Individuals with psychiatric disorder who committed suicide by drowning10–89 X X
Flaig et al., 2013 [62]2006–2010GermanyEurope and Central AsiaHICIII-3Autopsied non-natural deaths18–96X X
Furumiya et al., 2015 [36]2003–2013JapanEast Asia and PacificHICIVElderly persons with dementia who died outdoors after wandering70–94X X
Guay et al., 2019 [63]2005–2014CanadaNorth AmericaHICIII-3Bathtub drownings in the province of Quebec65+X X
Haines et al., 2010 [64]-AustraliaEast Asia and PacificHICIII-3Completed suicides in Tasmania-X X
Harris et al., 2010 [84]2006USANorth AmericaHICIII-3Sanctioned triathlete events-X X
Harris et al., 2017 [83]1985–2016USANorth AmericaHICIVSanctioned triathlete events15–80X X
Hong et al., 2013 [103]2004South KoreaEast Asia and PacificHICIII-3Korea National Hospital Discharge Survey0–65+X X
Hossain et al., 2017 [37]2003BangladeshSouth AsiaLMICIII-3Adult drowning 18+X X
Hunt et al., 2006 [65]1996–2000United KingdomEurope and Central AsiaHICIII-3Sample of cases of suicide in England and Wales with recent (<1 year) contact with mental health services0–75+X X
Jinda et al., 2019 [38]2004–2013ThailandEast Asia and PacificUMICIII-3Seizure-related injuries15–80+X X
Kaiboriboon, et al. 2014 [39]1992–2008USANorth AmericaHICIII-3Hospitalised epilepsy deaths18–64X X
Karlovich et al., 2020 [40]2014–2017USANorth AmericaHICIVDecedents with a history of seizure or epilepsy18–45X X
Kevrekidis et al., 2021 [85]2009–2018GreeceEurope and Central AsiaHICIII-3Retrospective case–control study of drowning deaths15–75+X X
Kielty et al., 2015 [66]2006–2016IrelandEurope and Central AsiaHICIII-3Probable suicide deaths18–55+X X
Kikuchi e al, 2019 [41]2015JapanEast Asia and PacificHICIVDementia patients missing after wandering<65–95+X X
Kim et al., 2021 [42]2008–2017South KoreaEast Asia and PacificHICIII-3Deaths of people with disabilities registered at Ministry of Health and Welfare0–80+X X
Kong et al., 2021 [102]2009–2019Hunan, ChinaEast Asia and PacificUMICIII-3Accidental deaths during pregnancy and puerperium-X X
Koo et al., 2019 [67]2000–2013AustraliaEast Asia and PacificHICIII-3Cases from the Queensland Suicide Register65+X X
Kotsiou et al., 2014 [104]2012–2013GreeceEurope and Central AsiaHICIII-3Drowning hospitalisations1888X X
Kumar et al. 2017 [72]2012–2014IndiaSouth AsiaLMICIVAttempted suicides in psychiatric consultation10–50 X X
Lawes et al., 2021 [68]2005–2019AustraliaEast Asia and PacificHICIII-3Suicidal deaths along the Australian coast18–70+X X
Lawes et al., 2021 [105]2004–2019AustraliaEast Asia and PacificHICIII-3Males (15–34 years) were compared with other adults (15 years and older)15+X X
Lee et al., 2019 [69]1997–2016South KoreaEast Asia and PacificHICIII-3Elderly drowning patients18–65+X XXX
Lippmann et al., 2021 [86]2007–2016New ZealandEast Asia and PacificHICIII-3Diving fatalities24–70X X
Ljusic et al., 2018 [70]2001–2010Republic of SerbiaEurope and Central AsiaUMICIII-3Suicide with mental disorders, somatic disorders or without registered disorder-X X
Lofman et al., 2011 [100]1988–2007FinlandEurope and Central AsiaHICIII-3Suicides in the province of Oulu in Northern Finland0–65+X X
Lunetta et al., 2020 [106]1971–2013FinlandEurope and Central AsiaHICIII-3Land motor vehicle drowning0–99+X X
Maity et al., 2020 [71]2012–2013IndiaSouth AsiaLMICIII-3Drowning deaths0–70X X
Markarian et al., 2020 [43]2014–2017FranceEurope and Central AsiaHICIII-3Adult (>18 years of age) ICU admissions40–74X X
Mateen et al., 2012 [44]2005–2008BangladeshSouth AsiaLMICIII-3Accidental injury death in people with epilepsy12–58X X
Mbizvo et al., 2021 [45]2009–2016ScotlandEurope and Central AsiaHICIII-3Non SUDEP epilepsy related deaths≥16X X
Meyer-Rochow et al., 2015 [99]1982–2011FinlandEurope and Central AsiaHICIII-3Suicides among visually impaired persons20–65+X X
Mishima et al., 2018 [87]2016JapanEast Asia and PacificHICIVBath-related deaths34–92X X
Morgan et al., 2008 [88]2001–2005AustraliaEast Asia and PacificHICIII-3Surf beach swimmers and surfers13–86X X
Morris et al., 2016 [46]2002–2011South AfricaSub-Saharan AfricaUMICIII-3Bodies retrieved from water and immersion-related deaths in Pretoria18+X X
Mu et al., 2011 [47]2005–2009ChinaEast Asia and PacificUMICIVDeath among people with convulsive epilepsy in rural West China<15–66+X X
Neves et al., 2020 [48]-Portugal & UKEurope and Central AsiaHICIVPatients with Parkinson’s DiseaseMean = 64 XX
Nishida et al., 2015 [73]2006–2013JapanEast Asia and PacificHICIVPatients diagnosed with early post stroke depression who died65–94X X
Okuda et al., 2015 [49]2003–2013USANorth AmericaHICIVDeaths in bathtubs22–96X XX
Pan et al., 2021 [74]2001–2016TaiwanEast Asia and PacificHICIII-3Suicide mortality in patients with schizophrenia<20−
≥80+		X X
Papadodima et al., 2007 [89]1997–2004GreeceEurope and Central AsiaHICIII-3Drowning deaths<15–74+X X
Park et al., 2013 [75]1995–2006South KoreaEast Asia and PacificHICIII-3Psychiatric patients who suicide10–70+X X
Peden et al., 2019 [108]2005–2014Australia/Canada/NZ-HICIII-3Residents0–65+X X X
Peden et al., 2016 [57]2002–2012AustraliaEast Asia and PacificHICIII-3River drowning0–75+X X X
Peden et al., 2016 [107]2002–2012AustraliaEast Asia and PacificHICIII-3International tourists to Australia0–55+X X X
Peden et al., 2019 [19]2002–2012AustraliaEast Asia and PacificHICIII-3Bathtub drowning65–85+X X X
Purandare et al., 2009 [50]1996–2004United KingdomEurope and Central AsiaHICIII-3Suicide among those with dementia65+X X
Reizine et al., 2021 [76]2013–2020FranceEurope and Central AsiaHICIVDrowning in fresh and sea waterMean 68XXXX
Rowe et al., 2011 [51]2003–2008USANorth AmericaHICIVPersons with dementia who go missing40–95X X
Runeson et al., 2010 [77]1973–1982SwedenEurope and Central AsiaHICIII-3Completed suicides among those treated for attempted suicide10+X X
Satoh et al., 2013 [20]1998–2007JapanEast Asia and PacificHICIII-3Sudden deaths in hot bathtubs8–95X X
Schaffer et al., 2014 [78]1998–2010CanadaNorth AmericaHICIII-3Suicide in bipolar disorder<24–65+X X
Schneppe et al., 2021 [90]1997–2017GermanyEurope and Central AsiaHICIVDeaths in water1–90X XX
Selvaraj et al., 2020 [79]2017–2018IndiaSouth AsiaLMICIVDrowning in Madurai Region0–70+X XX
Sillanpaa et al., 2010 [52]1964–2002FinlandEurope and Central AsiaHICIVLong-term mortality among those with childhood-onset epilepsy1–50X X
Stemberga et al., 2010 [80]1981–2005CroatiaEurope and Central AsiaHICIII-3Suicidal drowning deaths23–86X X
Stephenson et al., 2020 [81]1988–2017AustraliaEast Asia and PacificHICIVUrban section of the River Torrens18–76X XX
Suzuki et al., 2015 [53]2009–2011JapanEast Asia and PacificHICIII-3Autopsied bath-related deaths0–90+X X
Tellier et al., 2019 [54]2011–2016FranceEurope and Central AsiaHICIII-3Gironde surf beaches0–65+X X
Tester et al., 2011 [91]1998–2010USANorth AmericaHICIVUnexplained drowning victims referred for a cardiac channel molecular autopsy3.5–69X X
Tikka et al., 2021 [92]1975–2015FinlandEurope and Central AsiaHICIVLand motor traffic crash related drowningsMean 34.7X XX
Tzimas et al., 2016 [93]2003–2011GermanyEurope and Central AsiaHICIVWater-related deaths with adequate genetic material for DNA analysis20–50X X
Vinkel et al., 2016 [94]1999–2012DenmarkEurope and Central AsiaHICIII-3Diving-related fatalities21–59X X
Walker et al., 2006 [95]2001AustraliaEast Asia and PacificHICIII-3Diving-related fatalities21–81X X
Walker et al., 2009 [96]2004AustraliaEast Asia and PacificHICIII-3Diving-related fatalities20–65X X
Williams et al., 2018 [82]2013–2017USANorth AmericaHICIII-3Actively serving US armed forces<20–40 + yearsXXX
Wingren et al., 2016 [101]1999–2013SwedenEurope and Central AsiaHICIII-3Suicide where body mass index was known18–70+X X
Yang et al., 2018 [55]2008–2015South KoreaEast Asia and PacificHICIII-3Bath-related deaths18–91X X
Youn et al., 2009 [56]1998–2007South KoreaEast Asia and PacificHICIII-3OHCA due to drowning patents admitted to St Mary’s Hospital3–87X XX
Abbreviations: HIC—high income country; LMIC—lower middle income country; LIC—low income country; OHCA—Out of Hospital Cardiac Arrest; UMIIC—upper middle income country; SUDEP—Sudden Unexpected Death in Epilepsy; UK—United Kingdom; Study evidence level: III-3 (comparative studies with concurrent controls and allocation not randomised (cohort studies), case control studies, or interrupted time series with a control group; Level IV (case studies with either post-test or pre-test/post-test outcomes).

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Ijerph 19 08863 g001 550
Figure 1. PRISMA flow chart.
Figure 1. PRISMA flow chart.
Ijerph 19 08863 g001
Table
Table 1. Inclusion and exclusion criteria.
Table 1. Inclusion and exclusion criteria.
InclusionExclusion
Peer-review literature, 1 January 2005 to 31 October 2021, English, globalOutside date range, non-English language, non-peer-reviewed
Limited to humansNon-human
Primary researchProtocols, literature reviews
Unintentional drowning-
Intentional self-harm drowningHomicide, assault, criminal behaviour
Data from primary analytical studies that include an unintentional drowning or submersion in water AND a medical condition (physiological or psychological) of any description. Acute conditions such as recent musculoskeletal injuries were excluded (i.e., broken arm during experience due to the drowning event)
Recreational drowning and commercial sub-populations (i.e., fisherman)-
Medical conditions could be known or unknown by the drowning victim prior to the drowning event (i.e., undiagnosed cardiac arrythmia or epilepsy)Conditions which were not chronic in nature or occurred as a result of the drowning incident (i.e., pulmonary oedema).
Sample comprised of adult population only
or a minimum of 75% of sample
or age group could be easily extracted from main data set of relevant studies		Study population aged 0–14 years only, or population aged 15 years or over could not be disaggregated
Case reports included if reports ≥ 6 cases and include a population and provides some indication of riskStudies reporting < 6 cases.
Table
Table 2. Medical condition groupings and examples of included conditions.
Table 2. Medical condition groupings and examples of included conditions.
Medical Condition GroupSub-CategorisationExamples of Included Conditions
Diseases of the circulatory systemAneurysm and dissectionsAortic aneurysm and dissection
AtherosclerosisAtherosclerosis
CardiomyopathiesHypertrophic cardiomyopathy
Congenital Heart DiseaseCongenital coronary arterial anomaly
Heart ArrythmiasCardiac arrythmia, Long QT, Cardiac channel mutation, Syncope/Other, Wolf-Parkinson White Syndrome
Hypertensive Heart DiseaseHeart hypertrophy, Left Ventricle Hypertrophy
Hypertensive Vascular DiseasePresence of cardia and vascular implants and grafts, blood pressure problems
Ischemic Heart DiseaseCoronary artery atherosclerosis;
Ischaemic heart disease, coronary artery stenosis, recent myocardial infarction
Diseases of the digestive system Digestive disease
Diseases of the ear and mastoid Hearing impairment
Diseases of the eye and adnexa Blindness; low vision; visual impairment
Diseases of the genitourinary system Kidney dysfunction
Diseases of the musculoskeletal system and connective tissue Physical disability
Diseases of the nervous systemDementiaDementia
Seizure disordersConvulsive epilepsy; epilepsy
Neurological mobility disordersMobility disturbance; Parkinson’s Disease
OtherDisability of brain lesion; central nervous system disease; nervous disease
Nervous system (no further breakdown)-
Diseases of the respiratory system Asthma; respiratory disease
Endocrine, nutritional, and metabolic diseases Diabetes; dyslipidemia; obese; overweight; underweight
Mental and behavioural conditionsAnxiety DisorderAnxiety disorder
Behavioural DisorderSomatic disorders, somatic comorbidity, behavioural syndromes associated with psychological disturbances and physical factors
Cognitive FunctionIntellectual disability, mental retardation, senile dementia, disorders of psychological development, organic brain disorders
Mood DisorderDepression, bipolar disorder, affective disorder, depressive disorders
Personality DisorderPersonality disorder
Psychosexual disordersPsychosexual disorders
Psychotic DisorderPsychiatric disorders, schizophrenia, non-organic psychotic disorder, neurotic disorders
Substance Abuse DisordersAlcoholism, drug dependence, poisoning
Other DisordersOther disorders (organic disorders)
Neoplasms Cancer
Symptoms, signs and conditions not elsewhere classified Pregnancy
Table
Table 3. Grouped medical condition by included studies.
Table 3. Grouped medical condition by included studies.
Medical Condition GroupedNumber of Studies% of All Included Studies (n = 83)Reference(s)
Diseases of the circulatory system2530.1[19,43,46,49,53,54,55,57,63,76,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98]
Diseases of the digestive system11.2[53]
Diseases of the ear and mastoid11.2[42]
Diseases of the eye and adnexa22.4[42,99]
Diseases of the genito-urinary system22.4[42,53]
Diseases of the musculoskeletal system and connective tissue33.6[19,42,100]
Diseases of the nervous system3238.6[7,11,19,20,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57]
Diseases of the respiratory system56.0[42,43,53,54,76]
Endocrine, nutritional, and metabolic diseases67.2[11,53,56,63,76,101]
Mental and behavioural conditions3137.3[7,37,42,43,54,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82]
Neoplasms22.4[53,80]
Symptoms, signs, and conditions not elsewhere classified11.2[102]
Note: some papers included more than one medical condition, hence the total adds to more than the total number of included studies (83).
Table
Table 4. Studies reporting conditions within the diseases of the nervous system category.
Table 4. Studies reporting conditions within the diseases of the nervous system category.
ConditionReferenceCountryStudy PopulationAge GroupIntentOutcome% Who Drowned% Who Drowned with Med Conditions% Who Drowned with Condition
DementiaFurumiya et al., 2015 [36]JapanOutdoor wandering deaths70–94 yearsUF -42.1%
Kikuchi et al., 2019 [41]JapanWandering deaths among those with dementia All agesUF -11.3%
Purandare et al., 2009 [50]UKSuicide among those with dementia65+ yearsIF -17.8%
Rowe et al., 2011 [51]USAPersons with dementia who go missing40–95 yearsUF -11.4
Seizure disordersBain et al., 2018 [11]CanadaEpilepsy or seizure with suspicion of drowning12–68 yearsUF 100.0%
Barooni et al., 2007 [30]CanadaEpilepsy drowning deaths0–90 yearsUF4.1% 100%
Chang et al., 2012 [33]TaiwanDeaths in those with epilepsyAll agesUF 0.3%
Chang et al., 2014 [32]USAEpilepsy on death certificatesAll agesUF 0.21 *
Cihan et al., 2018 [34]USAEpilepsy deaths in water20–73 yearsUF--2.7%
Ding et al., 2013 [35]ChinaEpilepsy diagnosis follow-up 10–69 yearsU,I,UndF 1.4%
Hossain et al., 2017 [37]BangladeshAdult drowning18+ yearsUF9.6%
Jinda et al., 2019 [38]ThailandSeizure related injuries15+ yearsUF 0.05%
Kaiboriboon et al., 2014 [39]USAHospitalised epilepsy deaths18–64 yearsUF 0.4%
Karlovich et al., 2020 [40]USADeaths in people with history of seizure18–45 yearsUF 0.2%
Markarian et al., 2020 [43]FranceSelected patients admitted to ICU for a drowning-related incident40–74 yearsUF7.7%7.8%-
Mateen et al., 2012 [44]BangladeshAccidental injury death in people with epilepsy 12–58 yearsUF 83.3%
Mbizvo et al., 2021 [45]ScotlandNon SUDEP epilepsy related deaths≥16 yearsUF 4.4%
Morris et al., 2016 [46]South AfricaBodies retrieved from water and immersion related deaths18+ yearsUF3.2%60.0%-
Mu et al., 2011 [47]ChinaDeath among people with convulsive epilepsy>15 yearsUF--1.3%
Okuda et al. 2015 [49]USADeaths in bathtubs22–96 yearU,IF9.1%18.8%-
Peden et al., 2019 [19]AustraliaBathtub drownings65+ yearsUF6.3%7.7%-
Satoh et al., 2013 [20]JapanSudden deaths in hot bathtubs8–95 years UF11.1%--
Sillanpaa et al., 2010 [52]FinlandLong term mortality among those with childhood-onset epilepsy1–50 yearsUF--2.4%
Suzuki et al., 2015 [53]JapanAutopsied bath related deathsAll agesUF2.2%2.8%-
Tellier et al., 2019 [54]FranceDrowning victims along Gironde surf beachesAll agesUF0.2%2.0%-
Yang et al., 2018 [55]South KoreaBath-related deaths18–91 yearsUF3.5%4.0%-
Youn et al., 2009 [56]South KoreaOHCA due to drowning admitted to hospital3–87 yearsU,I,UndF1.8%14.3-
Neurological mobility disordersNeves et al., 2020 [48]Portugal & the UKPatients with Parkinson’s DiseaseM = 64 yearsUNF -49.1%
Satoh et al., 2013 [20]JapanSudden deaths in hot bathtubs8–95 years UF11.1%--
OtherKim et al., 2021 [42]South KoreaDeaths of people with a disabilityAll agesUF-4.4/100,000 *-
Okuda et al., 2015 [49]USADeaths in bathtubs22–96 yearU,IF-9.4%-
Suzuki et al., 2015 [53]JapanAutopsied bath related deathsAll agesUF1.1%--
Yang et al., 2018 [55]South KoreaBath-related deaths18–91 yearsUF5.3%6.0%-
Nervous system (no further breakdown)Cenderadewi et al., 2019 [7]AustraliaIntentional drowning deathsAll agesIF2.4%2.4%-
Peden et al., 2016 [57]AustraliaRiver drowning deathsAll agesUF1.7%4.4%-
Abbreviations: F = Fatal; I = Intentional; M = mean age; NF = Non-Fatal; OHCA = Out of Hospital Cardiac Arrest; SUDEP = Sudden Unexpected Death in Epilepsy; U = Unintentional; UK = United Kingdom; Und = Undetermined; USA = United States of America; * represents crude mortality rate per 100,000 population not proportion.
Table
Table 6. Studies reporting conditions within the diseases of the circulatory system category.
Table 6. Studies reporting conditions within the diseases of the circulatory system category.
ConditionReferenceCountryStudy PopulationAge GroupIntentOutcome% Who Drowned% Who Drowned with Med Conditions% Who Drowned with Condition
Aneurysms and DissectionsKevekidis et al., 2021 [85]GreeceDrowning deaths15–75+ yearsUF0.4%0.7%-
AtherosclerosisKevekidis et al., 2021 [85]GreeceDrowning deaths15–75+ yearsUF12.5%20.0%-
CardiomyopathiesKevekidis et al., 2021 [85]GreeceDrowning deaths15–75+ yearsUF9.6%14.1%-
Yang et al., 2018 [55]South KoreaBath-related deaths18–91 yearsUF1.8%2.0%-
Congenital heart diseaseHarris et al., 2017 [83]USASudden death during sanctioned triathlon 15–80 yearsUF11.1%--
Heart
arrythmias		Guay et al., 2019 [63]CanadaBathtub drownings people aged 65+65+ yearsUF21.7%--
Harris et al., 2010 [84]
Harris et al., 2017 [83]		USASudden death in USA Triathlon sanctioned events-UF11.1%--
Lippmann et al. 2021 [86]New ZealandBreath-hold diving fatalities24–70 yearsUF20.7%--
Peden et al., 2019 [19]AustraliaBathtub drownings65–85+ yearsUF15.6%19.2%-
Tester et al., 2011 [91]USAUnexplained drowning victims referred for a cardiac channel molecular autopsy3.5–69 yearsUF22.9%--
Walker et al., 2006 [95]AustraliaDiving-related fatalities21–81 yearsUF22.2%--
Walker et al., 2009 [96]AustraliaDiving-related fatalities20–65 yearsUF11.1%--
Hypertensive heart diseaseHarris et al., 2010 [84]USACompetitors in USA Triathlon sanctioned events-UF66.7%--
Harris et al., 2017 [83]USASudden death during sanctioned triathlon 15–80 yearsUF66.7%--
Hypertensive vascular
disease		Guay et al., 2019 [63]CanadaBathtub drownings people aged 65+65+ yearsUF15.2%--
Kevekidis et al., 2021 [85]GreeceDrowning deaths15–75+ yearsUF2.1%3.3%-
Schneppe et al., 2021 [90]GermanyDeaths in water1–90 yearsI, UF14.3%38.3%-
Ischaemic
heart disease		Kevekidis et al., 2021 [85]GreeceDrowning deaths15–75+ yearsUF87.9%---
Papadodima et al., 2007 [89]GreeceDrowning victims<15–74+ yearsUF51.8%--
Schneppe et al., 2021 [90]GermanyDeaths in water1–90 yearsI, UF23.0%61.7%-
Suzuki et al., 2015 [53]JapanAutopsied bath related deaths0–90+ yearsUF34.2%43.2%-
Yang et al., 2018 [55]South KoreaBath-related deaths18–91 yearsUF73.7%84.0%-
All
cardiovascular conditions		Claesson et al., 2013 [97]SwedenSwedish National Board of Forensic Medicine autopsied drowning cases22–71 yearsI, U, UndF10.1%--
Guay et al., 2019 [63]CanadaBathtub drownings people aged 65+65+ yearsUF6.5%30.0%-
Harris et al., 2010 [84]USACompetitors in USA Triathlon sanctioned events-UF77.8%--
Harris et al., 2017 [83]USASudden death during sanctioned triathlon 15–80 yearsUF77.8%--
Kevekidis et al., 2021 [85]GreeceDrowning deaths15–75+ yearsUF62.5%-
Lippmann et al. 2021 [86]New ZealandBreath-hold diving fatalities24–70 yearsUF34.5%--
Markarian et al., 2020 [43]FranceSelected patients admitted to ICU for a drowning-related incident40–74 yearsIF35.6%26.0%--
Mishima et al., 2018 [87]JapanBath-related deaths34–92 yearsUF24.4%28.6%-
Morgan et al., 2008 [88]AustraliaSurf beach swimmers and surfers13–86 yearsUF26.4%87.2%-
Morris et al., 2016 [46]South AfricaBodies retrieved from water and immersion related deaths18+ yearsUF4.8%40.0%-
Okuda et al., 2015 [49]USADeaths in bathtubs22–96 yearU,IF30.3%62.5%-
Peden et al., 2016 [57]AustraliaRiver drowning deaths0–75+ yearsUF5.6%14.8%-
Peden et al., 2019 [19]AustraliaBathtub drownings65–85+ yearsUF43.8%53.8%-
Reizine et al., 2021 [76]FranceDeath after non-fatal drowning in fresh and sea waterM age = 68 yearsI,UF10.7%14.5%-
Suzuki et al., 2015 [53]JapanAutopsied bath related deaths0–90+ yearsUF50.9%64.4%-
Tellier et al., 2019 [54]FranceDrowning victims along Gironde surf beaches0–65+ yearsUF3.0%34.7%-
Tikka et al., 2021 [92]FinlandLand motor traffic crash related drowningsM age = 34.7 yearsI,UF9.0%--
Vinkel et al., 2016 [94]DenmarkDiving-related fatalities21–59 yearsUF20.8%--
Yang et al., 2018 [55]South KoreaBath-related deaths18–91 yearsUF-86.0%-
Abbreviations: F = Fatal; I = Intentional; U = Unintentional; Und = Undetermined; USA = United States of America.
Table
Table 8. Drowning prevention strategies documented in included literature by medical condition.
Table 8. Drowning prevention strategies documented in included literature by medical condition.
Prevention
Strategy Coded		Prevention Strategy Free TextMedical Condition CategoryDrowning Intent Primary, Secondary or Tertiary Proposed (P), Implemented (I) or Evaluated (E)Hierarchy of ControlReference
EducationCounselling regarding drowning prevention for people with
epilepsy		Nervous system UnintentionalPrimaryPAdministrativeBain et al. 2018 [11]
EducationRoutinely warn people with epilepsy about the potential for
drowning while bathing		Nervous system UnintentionalPrimaryPAdministrative Bowman et al. 2010 [31]
EducationEncourage showering alternativelyNervous system UnintentionalPrimaryPSubstitutionBowman et al. 2010 [31]
EducationChildren and those who require dependent care, who may not be capable of showering, should not be left unattended in a bathtubNervous systemUnintentionalPrimaryPAdministrativeBowman e al 2010 [31]
EducationPromote impact of alcohol and substance misuseMental and
behavioural		IntentionalPrimaryPAdministrativeCenderadewi et al. 2019 [7]
EducationSupervision and specific bathing precautions could be effective
prevention strategies		Nervous system UnintentionalPrimaryPAdministrativeCihan et al., 2018 [34]
EducationPolicymakers and healthcare professionals should increase public awareness that people whose families consider their cognitive function normal or normal for their age can go missingNervous system UnintentionalSecondaryPAdministrativeKikuchi et al., 2019 [41]
EducationWater safety programs for people of all ages with epilepsy,
appropriate for level of ability		Nervous system UnintentionalPrimaryPAdministrativeMateen et al., 2012 [44]
EducationEducating people with epilepsy and their carers of the risks of drowningNervous systemUnintentionalPrimaryPAdministrativeMu et al., 2011 [47]
EducationAlert those with Parkinson’s Disease to the potential risks associated with swimming and the need to understand the disease-related features that contribute to the changes in swimming performanceNervous systemUnintentionalPrimaryPAdministrativeNeves et al., 2020 [48]
EducationIncreased GP and carer awareness of role of medical conditions and bathtub drowning riskAll pre-existing medical conditionsUnintentionalPrimaryPAdministrativePeden et al., 2019 [19]
EducationShowering is a safer solution especially where showering aids such as chairs are usedAll pre-existing medical conditionsUnintentionalPrimaryPSubstitutionPeden et al., 2019 [19]
EducationFamily members should pay attention to elderly people who have circulatory diseases during bathing, particularly in winterCirculatory systemUnintentionalPrimaryPAdministrativeSuzuki et al., 2015 [53]
GuidelinesPrevention and treatment guidelines developedNervous systemUnintentionalPrimaryPAdministrativeMu et al., 2011 [47]
Policy Prevent dementia patients who live alone from going missing and ensure their absence is noticed immediatelyNervous system UnintentionalPrimaryPAdministrativeKikuchi et al., 2019 [41]
Policy Local governments should appeal to inhabitants for cooperation with search activitiesNervous system UnintentionalSecondaryPAdministrativeKikuchi et al., 2019 [41]
Policy Local governments, police stations and MESN should be prepared to initiate search activities immediatelyNervous system UnintentionalSecondaryPAdministrativeKikuchi et al., 2019 [41]
TestingPatients with cardiovascular disease, and particularly those with infarctions, should undergo special testing (e.g., Holter monitoring during swimming)Circulatory systemUnintentionalPrimaryPAdministrativePapadodima et al., 2007 [89]
TestingA medical check-up for those who go divingCirculatory systemUnintentionalPrimaryPAdministrativePeden et al., 2016 [57]
Testing (genetic)Testing considered in post-mortem evaluation of unexplained drowning, especially if positive personal or family history is elicited to identify cardiac channel mutationCirculatory systemUnintentionalPrimaryPAdministrativeTester et al., 2011 [91]
TestingOver 45 years of age, divers and snorkelers should have their
cardiovascular health periodically assessed by a dive doctor,
preferably well aware of the cardiovascular stressors associated with diving and snorkelling		Circulatory systemUnintentionalPrimaryPAdministrativeWalker et al., 2009 [96]
TrainingBystander rescue and CPR trainingMental and
behavioural		IntentionalSecondary (rescue)
Tertiary (CPR)		PAdministrativeCenderadewi et al. 2019 [7]
TrainingDevelopment of suicide-response training by surf lifesaving
volunteers		Mental and
behavioural		IntentionalPrimaryPAdministrativeLawes et al., 2021 [68]
TreatmentDesign a comprehensive psychiatric assessment and management plan, by promoting identification, treatment and follow-up of individuals with psychiatric conditionsMental and
behavioural		IntentionalPrimaryPAdministrativeCenderadewi et al. 2019 [7]
TreatmentIntensified aftercare is warranted after suicide attemptsMental and
behavioural		IntentionalPrimaryPAdministrativeRuneson et al., 2010 [77]
Abbreviations: CPR = Cardio-pulmonary Resuscitation; GP = General Practitioner; MESN = Missing Elderly Search Network.
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Peden, A.E.; Taylor, D.H.; Franklin, R.C. Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning. Int. J. Environ. Res. Public Health 2022, 19, 8863. https://doi.org/10.3390/ijerph19148863

AMA Style

Peden AE, Taylor DH, Franklin RC. Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning. International Journal of Environmental Research and Public Health. 2022; 19(14):8863. https://doi.org/10.3390/ijerph19148863

Chicago/Turabian Style

Peden, Amy E., Danielle H. Taylor, and Richard C. Franklin. 2022. "Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning" International Journal of Environmental Research and Public Health 19, no. 14: 8863. https://doi.org/10.3390/ijerph19148863

APA Style

Peden, A. E., Taylor, D. H., & Franklin, R. C. (2022). Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning. International Journal of Environmental Research and Public Health, 19(14), 8863. https://doi.org/10.3390/ijerph19148863

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