Evie Summers
Sleep disturbances are common in people with liver disease, with 60-80% of patients with chronic liver disease reporting poor sleep. This can negatively impact patients' quality of life, cognitive functions, and increase mortality. While the underlying causes are complex and not yet fully understood, they may include disturbed metabolism of melatonin and glucose, alterations in thermoregulation, and altered ghrelin secretion profiles. Sleep disturbances can also be an early sign of hepatic encephalopathy, although many patients without HE also complain of poor sleep. To help manage sleep patterns, patients can create a bedtime routine, develop a comfortable bedroom environment, keep a sleep diary, and practice distraction techniques.
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What You'll Learn
Create a bedtime routine
Sleep plays a crucial role in our overall health and wellbeing. Adults are recommended to sleep for an average of 7-9 hours per night. However, liver conditions can affect your sleep patterns. Here are some tips to create a bedtime routine to promote better sleep:
Establish a Daytime Routine
A daytime routine can help promote a good night's sleep. This includes waking up at the same time every day, planning meals for the same time each day, avoiding late naps, and exercising regularly. Aim for at least 30 minutes of exercise daily, but avoid exercising too late in the evening as it may interfere with your sleep.
Develop a Relaxing Bedtime Ritual
Create a calming bedtime routine to help your body relax and prepare for sleep. This includes avoiding caffeinated drinks in the early evening, as well as refraining from alcohol and smoking, which can negatively impact your sleep. Instead, try incorporating relaxing activities such as taking a warm bath, listening to soft music, meditation, or drinking a warm, milky drink.
Create a Comfortable Bedroom Environment
Make your bedroom conducive to sleep by keeping it dark with blackout blinds or curtains, and using an eye mask if needed. Maintain a comfortable temperature, and consider using earplugs if noise is an issue. Additionally, avoid using electronic devices such as phones, tablets, or computers before bed, as the blue light from these devices can activate your brain and make it harder to fall asleep.
Distraction Techniques and Sleep Diaries
If you find yourself lying awake in bed, try distraction techniques such as going through the alphabet and naming items that start with each letter. You can also keep a sleep diary to identify patterns of sleep disturbances. This can help you make informed changes to improve your sleep quality.
It is important to note that these suggestions are general recommendations. Always consult with a healthcare professional for personalized advice and to discuss any specific concerns or symptoms related to liver disease and sleep.
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Make your bedroom comfortable
Sleep is an essential part of our overall well-being. Adults are recommended to sleep for an average of 7 to 9 hours per night. Having a liver condition can affect your sleeping patterns. However, there are some things you can do to improve your sleep quality. Here are some tips to make your bedroom comfortable and promote better sleep:
Maintain a comfortable temperature
A cooler room and bed can reduce night sweats and improve sleep quality. The ideal bedroom temperature for sleeping is generally considered to be 65°F (18.3°C). This may be achieved by using air conditioning, ceiling fans, electric fans, or opening windows during cooler nights. You can also invest in cooling mattress pads and lightweight bedding to stay comfortable.
Create a dark environment
Darkness is essential for deep and restorative sleep. Minimise light sources in your bedroom by turning off or covering electronic lights. Use blackout curtains or window shades to block external light. If blocking all light is not feasible, consider using a comfortable sleep mask.
Reduce noise
Noise can affect your sleep cycles, even if you don't remember waking up. If you are disturbed by noise, try using earplugs or a white noise machine to block out or drown out unwanted sounds.
Choose comfortable bedding
Invest in a good-quality mattress, bedding, and pillows. A good pillow should support the alignment of your spine during sleep, reducing neck pain and promoting better sleep. Side sleepers may prefer firmer, fuller pillows, while thin, soft pillows are better for stomach sleepers. Medium firmness might be best if you sleep on your back. Additionally, wash your sheets and pillowcases regularly to reduce bacteria and allergens that could make sleep less comfortable.
Avoid electronics
The stimulation and light emitted from screens can disrupt sleep. Avoid watching TV or using electronic devices before bed, and do not use your bed for any activities other than sleeping.
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Keep a sleep diary
Sleep disturbances are common in people with liver disease, and they can have a negative impact on quality of life. If you are having trouble sleeping due to liver disease, it may be helpful to keep a sleep diary.
A sleep diary is a record of your sleeping patterns and can be used to identify patterns of sleep or trouble sleeping. Keeping a sleep diary can help you figure out if there are any changes you can make to improve your sleep. For example, you may notice that you sleep better when you go to bed earlier or when you avoid caffeine after a certain time of day.
Your sleep diary can also be a useful tool to discuss with your doctor, who may be able to suggest other options to help you sleep better. There are also various apps and websites that can help you track your sleep and provide guidance on improving your sleep hygiene.
- The time you went to bed and the time you woke up
- How long it took you to fall asleep
- How many times you woke up during the night, and for how long
- The quality of your sleep (did you feel rested when you woke up, or tired and groggy?)
- Any activities or food/drink consumed before bed that may have impacted your sleep
- Any thoughts or worries that may have kept you awake
Remember to be consistent and record your sleep patterns every day, as this will help you identify patterns and make any necessary adjustments to improve your sleep.
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Consider medication
Sleep disturbances are a common feature of chronic liver disease (CLD), with 60-80% of patients with CLD reporting poor sleep. Insomnia, reduced sleep efficiency, increased sleep latency, reduced time in rapid eye movement (REM) sleep, restless leg syndrome, and excessive daytime sleepiness (EDS) are all common presentations of sleep disturbances in CLD. The cause of sleep disturbances in CLD is likely multifactorial and may be disease-specific, requiring tailored management strategies.
Non-pharmacological interventions are typically recommended as the first-line treatment for sleep disturbances in patients with liver disease. These include creating a positive and calming bedtime routine, improving the bedroom environment, and practising relaxation techniques or cognitive and psychological therapies such as mindfulness. However, in cases where non-pharmacological interventions are insufficient or impractical, certain medications may be considered to manage sleep disturbances in patients with liver disease.
Melatonin
Melatonin is a hormone that plays a key role in regulating the sleep-wake cycle, and its metabolism is often altered in patients with CLD, leading to sleep disturbances. Small randomised controlled trials have investigated the use of exogenous melatonin to improve sleep in patients with cirrhosis, but formal studies are still needed to establish its risks and benefits in this population. Melatonin should be used with caution and only under expert medical supervision.
Zolpidem
Zolpidem is a sedative-hypnotic medication that acts on the GABA receptors in the brain, promoting sleep. Similar to melatonin, there is limited evidence from small trials on the use of zolpidem in patients with cirrhosis, and more research is required to understand its risks and benefits fully. Zolpidem should only be used under the guidance of a healthcare professional and may be reserved for short-term use or when other interventions are ineffective.
Lactulose and Rifaximin
Lactulose and rifaximin are often used to treat hepatic encephalopathy (HE), a complication of liver disease that can cause sleep disturbances. Studies have shown that these medications can improve sleep in patients with cirrhosis and HE. However, it is important to note that these medications may not be suitable for all patients and should be used with caution under medical supervision.
Histamine (H1) Blockers
Histamine (H1) blockers, also known as antihistamines, are commonly used to treat allergies, but they can also help with sleep. While they may not be a first-line treatment for sleep disturbances in liver disease, they can be considered as part of a comprehensive management plan, especially if allergies or other conditions are contributing to sleep problems.
It is important to remember that medication use should always be discussed with a healthcare professional, as they can provide personalised advice and guidance based on an individual's medical history and current condition.
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Improve your sleep environment
Sleep disturbances are common in people with liver disease, and they can have a negative impact on quality of life. Here are some tips to improve your sleep environment:
Create a bedtime routine
Developing a calming bedtime routine can help relax your body and promote a good night's sleep. It is recommended to stop consuming caffeinated drinks in the early evening to allow enough time for the caffeine to leave your system before bedtime. Avoid alcohol and smoking, as these can negatively affect your sleep. Instead, include relaxing activities such as taking a warm bath, listening to soft music, meditation, or drinking a warm, milky drink to help your body wind down.
Improve your bedroom environment
Make sure your bedroom is dark, quiet, and comfortable. Use blackout blinds or curtains, and wear an eye mask if needed. Maintain a comfortable temperature, and consider using earplugs if noise is an issue. Try to associate your bed with sleep only, avoiding activities such as watching TV, using electronic devices, eating, or working in bed. Ensure you have a comfortable mattress and bedding suitable for the season.
Distraction techniques
If you find yourself lying awake in bed, try a distraction technique to focus your mind away from worrying thoughts. For example, go through the alphabet and name a flower, place, or item beginning with each letter. This can help take your mind off your thoughts and make it easier to fall asleep.
Late evening snacking
For those with cirrhosis, late evening snacking can be beneficial, but it is important to allow enough time between eating and lying down to prevent acid reflux and sleep disturbances. Planning your evening snack at least 1-2 hours before lying down can help prevent these issues.
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