What is the appropriate management for a 72-year-old patient with palpitations, sleep apnea, depression, skin cancer, and a ganglion cyst on the right wrist?

From the Guidelines

The patient's immediate priority should be to address her sleep apnea with renewed CPAP compliance and follow up with her cardiologist to evaluate her cardiac symptoms, as these conditions have a significant impact on her morbidity, mortality, and quality of life. For her cardiac symptoms (palpitations, elevated heart rate, and shortness of breath with exertion), she should follow up with her cardiologist as soon as possible, as it has been 2 years since her last visit 1. Her sleep apnea requires immediate attention with renewed CPAP compliance to reduce cardiovascular risk and improve oxygenation, as treatment of sleep-disordered breathing (SDB) can lead to a reduction in blood pressure and cardiovascular risk 1.

For depression management, switching from duloxetine back to citalopram may be appropriate if she previously had better response; this should be done with a gradual taper of duloxetine while starting citalopram at a low dose, considering the guidelines for screening, assessment, and care of anxiety and depressive symptoms in adults with cancer 1. The patient's skin cancer history necessitates prompt dermatology follow-up, with consideration for local options if transportation to Lubbock is difficult.

Regarding the right wrist mass (confirmed by MRI as a ganglion or synovial cyst), she should keep the referral appointment with the hand surgeon to discuss treatment options, which may include observation, aspiration, or surgical removal depending on symptoms. The referrals placed today for sleep study, cardiology, mammogram, and hand surgeon are all appropriate next steps to address her multiple medical issues comprehensively. Key considerations include:

• Sleep apnea management to reduce cardiovascular risk
• Cardiology follow-up for palpitations and shortness of breath
• Depression management with potential medication adjustment
• Dermatology follow-up for skin cancer history
• Hand surgeon evaluation for the wrist mass These steps are crucial for improving the patient's overall quality of life and reducing her risk of morbidity and mortality.

From the Research

Patient Concerns

• The patient is experiencing elevated heart rate when walking, increasing shortness of breath with exertion, and heart palpitations.
• The patient has a history of sleep apnea but is non-compliant with CPAP therapy.
• The patient has been taking duloxetine for 3-4 years but feels it's less effective than her previous citalopram and desires to switch back.
• The patient has a history of skin cancer and was referred to dermatology a year ago but missed the appointment due to transportation difficulties.
• The patient has had a mass on her right wrist since 2017, which an MRI from last year identified as a ganglion or synovial cyst.

Relationship Between Sleep Apnea and Depression

• Studies have shown that there is a link between sleep apnea syndrome (OSA) and depressive and anxiety symptoms 2, 3, 4.
• CPAP therapy has been shown to decrease depressive symptoms in patients with OSA 2, 3, 4.
• However, the effect of CPAP therapy on anxiety symptoms is less clear, with some studies showing no significant improvement 5, 3.
• Consistent adherence to CPAP therapy has been associated with improved healthcare resource utilization outcomes, including fewer self-harm events, emergency room visits, and hospitalizations 6.

Treatment Options

• CPAP therapy is the gold standard for sleep apnea treatment and should be considered as a first-line treatment for depression and anxiety symptoms in patients with OSA 2, 3.
• The patient's non-compliance with CPAP therapy should be addressed, and efforts should be made to improve adherence.
• The patient's depression treatment should be reassessed, and consideration should be given to switching back to citalopram or exploring other treatment options.

Referrals and Follow-up

• The patient has been referred to a cardiologist, sleep study, and hand surgeon, and follow-up appointments should be scheduled to monitor progress.
• The patient's skin cancer history and missed dermatology appointment should be addressed, and efforts should be made to reschedule the appointment.