A few diabetes papers of interest

1. Cognitive Dysfunction in Older Adults With Diabetes: What a Clinician Needs to Know. I’ve talked about these topics before here on the blog (see e.g. these posts on related topics), but this is a good summary article. I have added some observations from the paper below:

“Although cognitive dysfunction is associated with both type 1 and type 2 diabetes, there are several distinct differences observed in the domains of cognition affected in patients with these two types. Patients with type 1 diabetes are more likely to have diminished mental flexibility and slowing of mental speed, whereas learning and memory are largely not affected (8). Patients with type 2 diabetes show decline in executive function, memory, learning, attention, and psychomotor efficiency (9,10).”

“So far, it seems that the risk of cognitive dysfunction in type 2 diabetes may be influenced by glycemic control, hypoglycemia, inflammation, depression, and macro- and microvascular pathology (14). The cumulative impact of these conditions on the vascular etiology may further decrease the threshold at which cognition is affected by other neurological conditions in the aging brain. In patients with type 1 diabetes, it seems as though diabetes has a lesser impact on cognitive dysfunction than those patients with type 2 diabetes. […] Thus, the cognitive decline in patients with type 1 diabetes may be mild and may not interfere with their functionality until later years, when other aging-related factors become important. […] However, recent studies have shown a higher prevalence of cognitive dysfunction in older patients (>60 years of age) with type 1 diabetes (5).”

“Unlike other chronic diseases, diabetes self-care involves many behaviors that require various degrees of cognitive pliability and insight to perform proper self-care coordination and planning. Glucose monitoring, medications and/or insulin injections, pattern management, and diet and exercise timing require participation from different domains of cognitive function. In addition, the recognition, treatment, and prevention of hypoglycemia, which are critical for the older population, also depend in large part on having intact cognition.

The reason a clinician needs to recognize different domains of cognition affected in patients with diabetes is to understand which self-care behavior will be affected in that individual. […] For example, a patient with memory problems may forget to take insulin doses, forget to take medications/insulin on time, or forget to eat on time. […] Cognitively impaired patients using insulin are more likely to not know what to do in the event of low blood glucose or how to manage medication on sick days (34). Patients with diminished mental flexibility and processing speed may do well with a simple regimen but may fail if the regimen is too complex. In general, older patients with diabetes with cognitive dysfunction are less likely to be involved in diabetes self-care and glucose monitoring compared with age-matched control subjects (35). […] Other comorbidities associated with aging and diabetes also add to the burden of cognitive impairment and its impact on self-care abilities. For example, depression is associated with a greater decline in cognitive function in patients with type 2 diabetes (36). Depression also can independently negatively impact the motivation to practice self-care.”

“Recently, there is an increasing discomfort with the use of A1C as a sole parameter to define glycemic goals in the older population. Studies have shown that A1C values in the older population may not reflect the same estimated mean glucose as in the younger population. Possible reasons for this discrepancy are the commonly present comorbidities that impact red cell life span (e.g., anemia, uremia, renal dysfunction, blood transfusion, erythropoietin therapy) (45,46). In addition, A1C level does not reflect glucose excursions and variability. […] Thus, it is prudent to avoid A1C as the sole measure of glycemic goal in this population. […] In patients who need insulin therapy, simplification, also known as de-intensification of the regimen, is generally recommended in all frail patients, especially if they have cognitive dysfunction (37,49). However, the practice has not caught up with the recommendations as shown by large observational studies showing unnecessary intensive control in patients with diabetes and dementia (50–52).”

“With advances in the past few decades, we now see a larger number of patients with type 1 diabetes who are aging successfully and facing the new challenges that aging brings. […] Patients with type 1 diabetes are typically proactive in their disease management and highly disciplined. Cognitive dysfunction in these patients creates significant distress for the first time in their lives; they suddenly feel a “lack of control” over the disease they have managed for many decades. The addition of autonomic dysfunction, gastropathy, or neuropathy may result in wider glucose excursions. These patients are usually more afraid of hyperglycemia than hypoglycemia — both of which they have managed for many years. However, cognitive dysfunction in older adults with type 1 diabetes has been found to be associated with hypoglycemic unawareness and glucose variability (5), which in turn increases the risk of severe hypoglycemia (54). The need for goal changes to avoid hypoglycemia and accept some hyperglycemia can be very difficult for many of these patients.”

2. Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006–2013.

“From 2006 to 2013, use increased for metformin (from 47.6 to 53.5%), dipeptidyl peptidase 4 inhibitors (0.5 to 14.9%), and insulin (17.1 to 23.0%) but declined for sulfonylureas (38.8 to 30.8%) and thiazolidinediones (28.5 to 5.6%; all P < 0.001). […] The overall rate of severe hypoglycemia remained the same (1.3 per 100 person-years; P = 0.72), declined modestly among the oldest patients (from 2.9 to 2.3; P < 0.001), and remained high among those with two or more comorbidities (3.2 to 3.5; P = 0.36). […] During the recent 8-year period, the use of glucose-lowering drugs has changed dramatically among patients with T2DM. […] The use of older classes of medications, such as sulfonylureas and thiazolidinediones, declined. During this time, glycemic control of T2DM did not improve in the overall population and remained poor among nearly a quarter of the youngest patients. Rates of severe hypoglycemia remained largely unchanged, with the oldest patients and those with multiple comorbidities at highest risk. These findings raise questions about the value of the observed shifts in drug utilization toward newer and costlier medications.”

“Our findings are consistent with a prior study of drug prescribing in U.S. ambulatory practice conducted from 1997 to 2012 (2). In that study, similar increases in DPP-4 inhibitor and insulin analog prescribing were observed; these changes were accompanied by a 61% increase in drug expenditures (2). Our study extends these findings to drug utilization and demonstrates that these increases occurred in all age and comorbidity subgroups. […] In contrast, metformin use increased only modestly between 2006 and 2013 and remained relatively low among older patients and those with two or more comorbidities. Although metformin is recommended as first-line therapy (26), it may be underutilized as the initial agent for the treatment of T2DM (27). Its use may be additionally limited by coexisting contraindications, such as chronic kidney disease (28).”

“The proportion of patients with a diagnosis of diabetes who did not fill any glucose-lowering medications declined slightly (25.7 to 24.1%; P < 0.001).”

That is, one in four people who had a diagnosis of type 2 diabetes were not taking any prescription drugs for their health condition. I wonder how many of those people have read wikipedia articles like this one

“When considering treatment complexity, the use of oral monotherapy increased slightly (from 24.3 to 26.4%) and the use of multiple (two or more) oral agents declined (from 33.0 to 26.5%), whereas the use of insulin alone and in combination with oral agents increased (from 6.0 to 8.5% and from 11.1 to 14.6%, respectively; all P values <0.001).”

“Between 1987 and 2011, per person medical spending attributable to diabetes doubled (4). More than half of the increase was due to prescription drug spending (4). Despite these spending increases and greater utilization of newly developed medications, we showed no concurrent improvements in overall glycemic control or the rates of severe hypoglycemia in our study. Although the use of newer and more expensive agents may have other important benefits (44), further studies are needed to define the value and cost-effectiveness of current treatment options.”

iii. Among Low-Income Respondents With Diabetes, High-Deductible Versus No-Deductible Insurance Sharply Reduces Medical Service Use.

“Using the 2011–2013 Medical Expenditure Panel Survey, bivariate and regression analyses were conducted to compare demographic characteristics, medical service use, diabetes care, and health status among privately insured adult respondents with diabetes, aged 18–64 years (N = 1,461) by lower (<200% of the federal poverty level) and higher (≥200% of the federal poverty level) income and deductible vs. no deductible (ND), low deductible ($1,000/$2,400) (LD), and high deductible (>$1,000/$2,400) (HD). The National Health Interview Survey 2012–2014 was used to analyze differences in medical debt and delayed/avoided needed care among adult respondents with diabetes (n = 4,058) by income. […] Compared with privately insured respondents with diabetes with ND, privately insured lower-income respondents with diabetes with an LD report significant decreases in service use for primary care, checkups, and specialty visits (27%, 39%, and 77% lower, respectively), and respondents with an HD decrease use by 42%, 65%, and 86%, respectively. Higher-income respondents with an LD report significant decreases in specialty (28%) and emergency department (37%) visits.”

“The reduction in ambulatory visits made by lower-income respondents with ND compared with lower-income respondents with an LD or HD is far greater than for higher-income patients. […] The substantial reduction in checkup (preventive) and specialty visits by those with a lower income who have an HDHP [high-deductible health plan, US] implies a very different pattern of service use compared with lower-income respondents who have ND and with higher-income respondents. Though preventive visits require no out-of-pocket costs, reduced preventive service use with HDHPs is well established and might be the result of patients being unaware of this benefit or their concern about findings that could lead to additional expenses (31). Such sharply reduced service use by low-income respondents with diabetes may not be desirable. Patients with diabetes benefit from assessment of diabetes control, encouragement and reinforcement of behavior change and medication use, and early detection and treatment of diabetes complications or concomitant disease.”

iv. Long-term Mortality and End-Stage Renal Disease in a Type 1 Diabetes Population Diagnosed at Age 15–29 Years in Norway.

OBJECTIVE To study long-term mortality, causes of death, and end-stage renal disease (ESRD) in people diagnosed with type 1 diabetes at age 15–29 years.

RESEARCH DESIGN AND METHODS This nationwide, population-based cohort with type 1 diabetes diagnosed during 1978–1982 (n = 719) was followed from diagnosis until death, emigration, or September 2013. Linkages to the Norwegian Cause of Death Registry and the Norwegian Renal Registry provided information on causes of death and whether ESRD was present.

RESULTS During 30 years’ follow-up, 4.6% of participants developed ESRD and 20.6% (n = 148; 106 men and 42 women) died. Cumulative mortality by years since diagnosis was 6.0% (95% CI 4.5–8.0) at 10 years, 12.2% (10.0–14.8) at 20 years, and 18.4% (15.8–21.5) at 30 years. The SMR [standardized mortality ratio] was 4.4 (95% CI 3.7–5.1). Mean time from diagnosis of diabetes to ESRD was 23.6 years (range 14.2–33.5). Death was caused by chronic complications (32.2%), acute complications (20.5%), violent death (19.9%), or any other cause (27.4%). Death was related to alcohol in 15% of cases. SMR for alcohol-related death was 6.8 (95% CI 4.5–10.3), for cardiovascular death was 7.3 (5.4–10.0), and for violent death was 3.6 (2.3–5.3).

CONCLUSIONS The cumulative incidence of ESRD was low in this cohort with type 1 diabetes followed for 30 years. Mortality was 4.4 times that of the general population, and more than 50% of all deaths were caused by acute or chronic complications. A relatively high proportion of deaths were related to alcohol.”

Some additional observations from the paper:

“Studies assessing causes of death in type 1 diabetes are most frequently conducted in individuals diagnosed during childhood (17) or without evaluating the effect of age at diagnosis (8,9). Reports on causes of death in cohorts of patients diagnosed during late adolescence or young adulthood, with long-term follow-up, are less frequent (10). […] Adherence to treatment during this age is poor and the risk of acute diabetic complications is high (1316). Mortality may differ between those with diabetes diagnosed during this period of life and those diagnosed during childhood.”

“Mortality was between four and five times higher than in the general population […]. The excess mortality was similar for men […] and women […]. SMR was higher in the lower age bands — 6.7 (95% CI 3.9–11.5) at 15–24 years and 7.3 (95% CI 5.2–10.1) at 25–34 years — compared with the higher age bands: 3.7 (95% CI 2.7–4.9) at 45–54 years and 3.9 (95% CI 2.6–5.8) at 55–65 years […]. The Cox regression model showed that the risk of death increased significantly by age at diagnosis (HR 1.1; 95% CI 1.1–1.2; P < 0.001) and was eight to nine times higher if ESRD was present (HR 8.7; 95% CI 4.8–15.5; P < 0.0001). […] the underlying cause of death was diabetes in 57 individuals (39.0%), circulatory in 22 (15.1%), cancer in 18 (12.3%), accidents or intoxications in 20 (13.7%), suicide in 8 (5.5%), and any other cause in 21 (14.4%) […] In addition, diabetes contributed to death in 29.5% (n = 43) and CVD contributed to death in 10.9% (n = 29) of the 146 cases. Diabetes was mentioned on the death certificate for 68.2% of the cohort but for only 30.0% of the violent deaths. […] In 60% (88/146) of the cases the review committee considered death to be related to diabetes, whereas in 40% (58/146) the cause was unrelated to diabetes or had an unknown relation to diabetes. According to the clinical committee, acute complications caused death in 20.5% (30/146) of the cases; 20 individuals died as a result of DKA and 10 from hypoglycemia. […] Chronic complications caused the largest proportion of deaths (47/146; 32.2%) and increased with increasing duration of diabetes […]. Among individuals dying as a result of chronic complications (n = 47), CVD caused death in 94% (n = 44) and renal failure in 6% (n = 3). ESRD contributed to death in 22.7% (10/44) of those dying from CVD. Cardiovascular death occurred at mortality rates seven times higher than those in the general population […]. ESRD caused or contributed to death in 13 of 14 cases, when present.”

“Violence (intoxications, accidents, and suicides) was the leading cause of death before 10 years’ duration of diabetes; thereafter it was only a minor cause […] Insulin was used in two of seven suicides. […] According to the available medical records and autopsy reports, about 20% (29/146) of the deceased misused alcohol. In 15% (22/146) alcohol-related ICD-10 codes were listed on the death certificate (18% [19/106] of men and 8% [3/40] of women). In 10 cases the cause of death was uncertain but considered to be related to alcohol or diabetes […] The SMR for alcohol-related death was high when considering the underlying cause of death (5.0; 95% CI 2.5–10.0), and even higher when considering all alcohol-related ICD-10 codes listed on the death certificate (6.8; 95% CI 4.5–10.3). The cause of death was associated with alcohol in 21.8% (19/87) of those who died with less than 20 years’ diabetes duration. Drug abuse was noted on the death certificate in only two cases.”

“During follow-up, 33 individuals (4.6%; 22 men and 11 women) developed ESRD as a result of diabetic nephropathy. Mean time from diagnosis of diabetes to ESRD was 23.6 years (range 14.2–33.5 years). Cumulative incidence of ESRD by years since diagnosis of diabetes was 1.4% (95% CI 0.7–2.7) at 20 years and 4.8% (95% CI 3.4–6.9) at 30 years.”

“This study highlights three important findings. First, among individuals who were diagnosed with type 1 diabetes in late adolescence and early adulthood and had good access to health care, and who were followed for 30 years, mortality was four to five times that of the general population. Second, 15% of all deaths were associated with alcohol, and the SMR for alcohol-related deaths was 6.8. Third, there was a relatively low cumulative incidence of ESRD (4.8%) 30 years after the diagnosis of diabetes.

We report mortality higher than those from a large, population-based study from Finland that found cumulative mortality around 6% at 20 years’ and 15% at 30 years’ duration of diabetes among a population with age at onset and year of diagnosis similar to those in our cohort (10). The corresponding numbers in our cohort were 12% and 18%, respectively; the discrepancy was particularly high at 20 years. The SMR in the Finnish cohort was lower than that in our cohort (2.6–3.0 vs. 3.7–5.1), and those authors reported the SMR to be lower in late-onset diabetes (at age 15–29 years) compared with early-onset diabetes (at age 23). The differences between the Norwegian and Finnish data are difficult to explain since both reports are from countries with good access to health care and a high incidence of type 1 diabetes.”

However the reason for the somewhat different SMRs in these two reasonably similar countries may actually be quite simple – the important variable may be alcohol:

“Finland and Norway are appropriate to compare because they share important population and welfare characteristics. There are, however, significant differences in drinking levels and alcohol-related mortality: the Finnish population consumes more alcohol and the Norwegian population consumes less. The mortality rates for deaths related to alcohol are about three to four times higher in Finland than in Norway (30). […] The markedly higher SMR in our cohort can probably be explained by the lower mortality rates for alcohol-related mortality in the general population. […] In conclusion, the high mortality reported in this cohort with an onset of diabetes in late adolescence and young adulthood draws attention to people diagnosed during a vulnerable period of life. Both acute and chronic complications cause substantial premature mortality […] Our study suggests that increased awareness of alcohol-related death should be encouraged in clinics providing health care to this group of patients.”

April 23, 2017 Posted by | Diabetes, Economics, Epidemiology, Medicine, Nephrology, Neurology, Papers, Pharmacology, Psychology | Leave a comment

Biodemography of aging (IV)

My working assumption as I was reading part two of the book was that I would not be covering that part of the book in much detail here because it would simply be too much work to make such posts legible to the readership of this blog. However I then later, while writing this post, had the thought that given that almost nobody reads along here anyway (I’m not complaining, mind you – this is how I like it these days), the main beneficiary of my blog posts will always be myself, which lead to the related observation/notion that I should not be limiting my coverage of interesting stuff here simply because some hypothetical and probably nonexistent readership out there might not be able to follow the coverage. So when I started out writing this post I was working under the assumption that it would be my last post about the book, but I now feel sure that if I find the time I’ll add at least one more post about the book’s statistics coverage. On a related note I am explicitly making the observation here that this post was written for my benefit, not yours. You can read it if you like, or not, but it was not really written for you.

I have added bold a few places to emphasize key concepts and observations from the quoted paragraphs and in order to make the post easier for me to navigate later (all the italics below are on the other hand those of the authors of the book).

Biodemography is a multidisciplinary branch of science that unites under its umbrella various analytic approaches aimed at integrating biological knowledge and methods and traditional demographic analyses to shed more light on variability in mortality and health across populations and between individuals. Biodemography of aging is a special subfield of biodemography that focuses on understanding the impact of processes related to aging on health and longevity.”

“Mortality rates as a function of age are a cornerstone of many demographic analyses. The longitudinal age trajectories of biomarkers add a new dimension to the traditional demographic analyses: the mortality rate becomes a function of not only age but also of these biomarkers (with additional dependence on a set of sociodemographic variables). Such analyses should incorporate dynamic characteristics of trajectories of biomarkers to evaluate their impact on mortality or other outcomes of interest. Traditional analyses using baseline values of biomarkers (e.g., Cox proportional hazards or logistic regression models) do not take into account these dynamics. One approach to the evaluation of the impact of biomarkers on mortality rates is to use the Cox proportional hazards model with time-dependent covariates; this approach is used extensively in various applications and is available in all popular statistical packages. In such a model, the biomarker is considered a time-dependent covariate of the hazard rate and the corresponding regression parameter is estimated along with standard errors to make statistical inference on the direction and the significance of the effect of the biomarker on the outcome of interest (e.g., mortality). However, the choice of the analytic approach should not be governed exclusively by its simplicity or convenience of application. It is essential to consider whether the method gives meaningful and interpretable results relevant to the research agenda. In the particular case of biodemographic analyses, the Cox proportional hazards model with time-dependent covariates is not the best choice.

“Longitudinal studies of aging present special methodological challenges due to inherent characteristics of the data that need to be addressed in order to avoid biased inference. The challenges are related to the fact that the populations under study (aging individuals) experience substantial dropout rates related to death or poor health and often have co-morbid conditions related to the disease of interest. The standard assumption made in longitudinal analyses (although usually not explicitly mentioned in publications) is that dropout (e.g., death) is not associated with the outcome of interest. While this can be safely assumed in many general longitudinal studies (where, e.g., the main causes of dropout might be the administrative end of the study or moving out of the study area, which are presumably not related to the studied outcomes), the very nature of the longitudinal outcomes (e.g., measurements of some physiological biomarkers) analyzed in a longitudinal study of aging assumes that they are (at least hypothetically) related to the process of aging. Because the process of aging leads to the development of diseases and, eventually, death, in longitudinal studies of aging an assumption of non-association of the reason for dropout and the outcome of interest is, at best, risky, and usually is wrong. As an illustration, we found that the average trajectories of different physiological indices of individuals dying at earlier ages markedly deviate from those of long-lived individuals, both in the entire Framingham original cohort […] and also among carriers of specific alleles […] In such a situation, panel compositional changes due to attrition affect the averaging procedure and modify the averages in the total sample. Furthermore, biomarkers are subject to measurement error and random biological variability. They are usually collected intermittently at examination times which may be sparse and typically biomarkers are not observed at event times. It is well known in the statistical literature that ignoring measurement errors and biological variation in such variables and using their observed “raw” values as time-dependent covariates in a Cox regression model may lead to biased estimates and incorrect inferences […] Standard methods of survival analysis such as the Cox proportional hazards model (Cox 1972) with time-dependent covariates should be avoided in analyses of biomarkers measured with errors because they can lead to biased estimates.

“Statistical methods aimed at analyses of time-to-event data jointly with longitudinal measurements have become known in the mainstream biostatistical literature as “joint models for longitudinal and time-to-event data” (“survival” or “failure time” are often used interchangeably with “time-to-event”) or simply “joint models.” This is an active and fruitful area of biostatistics with an explosive growth in recent years. […] The standard joint model consists of two parts, the first representing the dynamics of longitudinal data (which is referred to as the “longitudinal sub-model”) and the second one modeling survival or, generally, time-to-event data (which is referred to as the “survival sub-model”). […] Numerous extensions of this basic model have appeared in the joint modeling literature in recent decades, providing great flexibility in applications to a wide range of practical problems. […] The standard parameterization of the joint model (11.2) assumes that the risk of the event at age t depends on the current “true” value of the longitudinal biomarker at this age. While this is a reasonable assumption in general, it may be argued that additional dynamic characteristics of the longitudinal trajectory can also play a role in the risk of death or onset of a disease. For example, if two individuals at the same age have exactly the same level of some biomarker at this age, but the trajectory for the first individual increases faster with age than that of the second one, then the first individual can have worse survival chances for subsequent years. […] Therefore, extensions of the basic parameterization of joint models allowing for dependence of the risk of an event on such dynamic characteristics of the longitudinal trajectory can provide additional opportunities for comprehensive analyses of relationships between the risks and longitudinal trajectories. Several authors have considered such extended models. […] joint models are computationally intensive and are sometimes prone to convergence problems [however such] models provide more efficient estimates of the effect of a covariate […] on the time-to-event outcome in the case in which there is […] an effect of the covariate on the longitudinal trajectory of a biomarker. This means that analyses of longitudinal and time-to-event data in joint models may require smaller sample sizes to achieve comparable statistical power with analyses based on time-to-event data alone (Chen et al. 2011).”

“To be useful as a tool for biodemographers and gerontologists who seek biological explanations for observed processes, models of longitudinal data should be based on realistic assumptions and reflect relevant knowledge accumulated in the field. An example is the shape of the risk functions. Epidemiological studies show that the conditional hazards of health and survival events considered as functions of risk factors often have U- or J-shapes […], so a model of aging-related changes should incorporate this information. In addition, risk variables, and, what is very important, their effects on the risks of corresponding health and survival events, experience aging-related changes and these can differ among individuals. […] An important class of models for joint analyses of longitudinal and time-to-event data incorporating a stochastic process for description of longitudinal measurements uses an epidemiologically-justified assumption of a quadratic hazard (i.e., U-shaped in general and J-shaped for variables that can take values only on one side of the U-curve) considered as a function of physiological variables. Quadratic hazard models have been developed and intensively applied in studies of human longitudinal data”.

“Various approaches to statistical model building and data analysis that incorporate unobserved heterogeneity are ubiquitous in different scientific disciplines. Unobserved heterogeneity in models of health and survival outcomes can arise because there may be relevant risk factors affecting an outcome of interest that are either unknown or not measured in the data. Frailty models introduce the concept of unobserved heterogeneity in survival analysis for time-to-event data. […] Individual age trajectories of biomarkers can differ due to various observed as well as unobserved (and unknown) factors and such individual differences propagate to differences in risks of related time-to-event outcomes such as the onset of a disease or death. […] The joint analysis of longitudinal and time-to-event data is the realm of a special area of biostatistics named “joint models for longitudinal and time-to-event data” or simply “joint models” […] Approaches that incorporate heterogeneity in populations through random variables with continuous distributions (as in the standard joint models and their extensions […]) assume that the risks of events and longitudinal trajectories follow similar patterns for all individuals in a population (e.g., that biomarkers change linearly with age for all individuals). Although such homogeneity in patterns can be justifiable for some applications, generally this is a rather strict assumption […] A population under study may consist of subpopulations with distinct patterns of longitudinal trajectories of biomarkers that can also have different effects on the time-to-event outcome in each subpopulation. When such subpopulations can be defined on the base of observed covariate(s), one can perform stratified analyses applying different models for each subpopulation. However, observed covariates may not capture the entire heterogeneity in the population in which case it may be useful to conceive of the population as consisting of latent subpopulations defined by unobserved characteristics. Special methodological approaches are necessary to accommodate such hidden heterogeneity. Within the joint modeling framework, a special class of models, joint latent class models, was developed to account for such heterogeneity […] The joint latent class model has three components. First, it is assumed that a population consists of a fixed number of (latent) subpopulations. The latent class indicator represents the latent class membership and the probability of belonging to the latent class is specified by a multinomial logistic regression function of observed covariates. It is assumed that individuals from different latent classes have different patterns of longitudinal trajectories of biomarkers and different risks of event. The key assumption of the model is conditional independence of the biomarker and the time-to-events given the latent classes. Then the class-specific models for the longitudinal and time-to-event outcomes constitute the second and third component of the model thus completing its specification. […] the latent class stochastic process model […] provides a useful tool for dealing with unobserved heterogeneity in joint analyses of longitudinal and time-to-event outcomes and taking into account hidden components of aging in their joint influence on health and longevity. This approach is also helpful for sensitivity analyses in applications of the original stochastic process model. We recommend starting the analyses with the original stochastic process model and estimating the model ignoring possible hidden heterogeneity in the population. Then the latent class stochastic process model can be applied to test hypotheses about the presence of hidden heterogeneity in the data in order to appropriately adjust the conclusions if a latent structure is revealed.”

The longitudinal genetic-demographic model (or the genetic-demographic model for longitudinal data) […] combines three sources of information in the likelihood function: (1) follow-up data on survival (or, generally, on some time-to-event) for genotyped individuals; (2) (cross-sectional) information on ages at biospecimen collection for genotyped individuals; and (3) follow-up data on survival for non-genotyped individuals. […] Such joint analyses of genotyped and non-genotyped individuals can result in substantial improvements in statistical power and accuracy of estimates compared to analyses of the genotyped subsample alone if the proportion of non-genotyped participants is large. Situations in which genetic information cannot be collected for all participants of longitudinal studies are not uncommon. They can arise for several reasons: (1) the longitudinal study may have started some time before genotyping was added to the study design so that some initially participating individuals dropped out of the study (i.e., died or were lost to follow-up) by the time of genetic data collection; (2) budget constraints prohibit obtaining genetic information for the entire sample; (3) some participants refuse to provide samples for genetic analyses. Nevertheless, even when genotyped individuals constitute a majority of the sample or the entire sample, application of such an approach is still beneficial […] The genetic stochastic process model […] adds a new dimension to genetic biodemographic analyses, combining information on longitudinal measurements of biomarkers available for participants of a longitudinal study with follow-up data and genetic information. Such joint analyses of different sources of information collected in both genotyped and non-genotyped individuals allow for more efficient use of the research potential of longitudinal data which otherwise remains underused when only genotyped individuals or only subsets of available information (e.g., only follow-up data on genotyped individuals) are involved in analyses. Similar to the longitudinal genetic-demographic model […], the benefits of combining data on genotyped and non-genotyped individuals in the genetic SPM come from the presence of common parameters describing characteristics of the model for genotyped and non-genotyped subsamples of the data. This takes into account the knowledge that the non-genotyped subsample is a mixture of carriers and non-carriers of the same alleles or genotypes represented in the genotyped subsample and applies the ideas of heterogeneity analyses […] When the non-genotyped subsample is substantially larger than the genotyped subsample, these joint analyses can lead to a noticeable increase in the power of statistical estimates of genetic parameters compared to estimates based only on information from the genotyped subsample. This approach is applicable not only to genetic data but to any discrete time-independent variable that is observed only for a subsample of individuals in a longitudinal study.

“Despite an existing tradition of interpreting differences in the shapes or parameters of the mortality rates (survival functions) resulting from the effects of exposure to different conditions or other interventions in terms of characteristics of individual aging, this practice has to be used with care. This is because such characteristics are difficult to interpret in terms of properties of external and internal processes affecting the chances of death. An important question then is: What kind of mortality model has to be developed to obtain parameters that are biologically interpretable? The purpose of this chapter is to describe an approach to mortality modeling that represents mortality rates in terms of parameters of physiological changes and declining health status accompanying the process of aging in humans. […] A traditional (demographic) description of changes in individual health/survival status is performed using a continuous-time random Markov process with a finite number of states, and age-dependent transition intensity functions (transitions rates). Transitions to the absorbing state are associated with death, and the corresponding transition intensity is a mortality rate. Although such a description characterizes connections between health and mortality, it does not allow for studying factors and mechanisms involved in the aging-related health decline. Numerous epidemiological studies provide compelling evidence that health transition rates are influenced by a number of factors. Some of them are fixed at the time of birth […]. Others experience stochastic changes over the life course […] The presence of such randomly changing influential factors violates the Markov assumption, and makes the description of aging-related changes in health status more complicated. […] The age dynamics of influential factors (e.g., physiological variables) in connection with mortality risks has been described using a stochastic process model of human mortality and aging […]. Recent extensions of this model have been used in analyses of longitudinal data on aging, health, and longevity, collected in the Framingham Heart Study […] This model and its extensions are described in terms of a Markov stochastic process satisfying a diffusion-type stochastic differential equation. The stochastic process is stopped at random times associated with individuals’ deaths. […] When an individual’s health status is taken into account, the coefficients of the stochastic differential equations become dependent on values of the jumping process. This dependence violates the Markov assumption and renders the conditional Gaussian property invalid. So the description of this (continuously changing) component of aging-related changes in the body also becomes more complicated. Since studying age trajectories of physiological states in connection with changes in health status and mortality would provide more realistic scenarios for analyses of available longitudinal data, it would be a good idea to find an appropriate mathematical description of the joint evolution of these interdependent processes in aging organisms. For this purpose, we propose a comprehensive model of human aging, health, and mortality in which the Markov assumption is fulfilled by a two-component stochastic process consisting of jumping and continuously changing processes. The jumping component is used to describe relatively fast changes in health status occurring at random times, and the continuous component describes relatively slow stochastic age-related changes of individual physiological states. […] The use of stochastic differential equations for random continuously changing covariates has been studied intensively in the analysis of longitudinal data […] Such a description is convenient since it captures the feedback mechanism typical of biological systems reflecting regular aging-related changes and takes into account the presence of random noise affecting individual trajectories. It also captures the dynamic connections between aging-related changes in health and physiological states, which are important in many applications.”

April 23, 2017 Posted by | Biology, Books, Demographics, Genetics, Mathematics, Statistics | Leave a comment