Assessment and Management of Sleep Disturbance in Cirrhosis

Abstract

Purpose of review: This review presents an in-depth overview of the sleep-wake phenotype of patients with cirrhosis, together with available pharmacological and non-pharmacological treatment strategies. A set of simple, practical recommendations is also provided.

Recent findings: The understanding of the pathophysiology of sleep disorders in this patient population has improved over the past decade, especially in relation to the interplay between homeostatic and circadian sleep regulation. In addition, new tools have been utilised for both screening and in-depth investigation of the sleep-wake profile of these patients. Finally, a number of studies have evaluated the efficacy of novel treatment strategies, often with encouraging results.

Summary: Since sleep disturbances are common in patients with cirrhosis, more so than in patients with other chronic diseases of similar severity, their assessment should become routine hepatological practice, along with the initiation of adequate treatment.

Keywords: Circadian rhythms; Hepatic encephalopathy; Insomnia; Sleep.

Fig. 1

Cirrhosis-associated abnormalities within the context the two-process model of sleep regulation (adapted and updated from Fig. 1 of Reference 9). (a) Normal interaction between the circadian oscillation in sleep propensity and the increase in homeostatic sleep pressure during the waking hours: the greater the distance between the two curves (23:00), the higher the sleep propensity (adapted from [20]). (b) Abnormal interaction between the homeostatic regulation (black line) and the delayed circadian rhythm (red dotted line) in a patient with cirrhosis; gray line: reference circadian oscillation in the healthy population. The lack of synchrony between the two processes leads to a jet-lag East-type sleep disorder, which could contribute to the observed difficulties in commencing (increased latency) and maintaining sleep (fragmentation) (adapted from [•]). (c) Abnormal interaction between homeostatic fluctuations (red broken line) and shifted/delayed circadian rhythm (red dotted line) in a patient with cirrhosis and HE; gray lines: reference circadian oscillation and homeostatic build-up in the healthy population. Hyperammonaemia/HE results in magnified and short-lived adenosine responses to the build-up of sleep pressure during the waking hours. This translates into an inability to generate slow-wave, restorative sleep and in a less efficient recovery from sleep deprivation.

Fig. 2

Practical recommendations for the assessment and management of sleep–wake disturbance in patients with cirrhosis