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function in activities appear (alz.org, 2015). These traditional three stages has been
used extensively in the clinical field. However, more evidence and analysis from both
genetic and clinical researches suggest the patho-physiological process of AD begins
before the diagnosis of AD even though the pathogenesis of AD remains unknown,
particularly in the early stages of the disease where therapies presumably would be
most effective. Many epidemiological studies suggest that the pathological process of
AD begins years before a clinical diagnosis is made (Li. C, 2015). In 2016, EJ. Mufson
and others have demonstrated that A plaques and NFTs are present in varying
degrees before the onset and throughout the progression of dementia. (EJ. Mufson,
2016) In the same year, another study suggests that BACE1 may serve as a sensitive
biomarker of early neuropathological changes before the diagnosis of AD (Lan Li, 2016).
All of this studies provide evidence that some of biomarkers have appeared
abnormalities in pre-symptomatic stage of AD progression which indicates that it is
critical to study the progression patterns in pre-symptomatic or prodromal phase
(Sperling et al., 2011). Note that the pathways of transitions from pre-symptomatic to
prodromal phase or from prodromal to clinical symptomatic phase are unclear, there is a
need to provide a more systematic and comprehensive assessment of the multiple
changes with the AD biomakers that occur during the transition from normal to MCI to
frank AD.
correlation of biomarkers (Madsen SK, 2015). However, the transition probability and
the AD progression pattern profile with the latent states are still unclear. Understanding
the dynamic disease process is critical in early detection and diagnosis. Therefore, a
framework for describing AD progression pattern with latent states is needed.
In this study, the latent transition model for AD progression is employed in where the AD
progression is modeled with a set of bio-markers. Different bio-markers for AD may
which are logistic regression coefficients for covariates predicting latent status
membership at baseline time point states; ii) a set of parameters which are logistic
regression coefficients for covariates predicting transitions over time. Here, assuming a
latent transition model with n estimated latent states can be estimated from C
categorical response measured at
as individual
is latent state membership at time 1, and so on; and I() as the indicator function which
equals 1 if y equals k and 0 otherwise; and as individual Is group membership, the
latent transition model can be expressed as:
For
In this study, since we have only two time points (baseline time point and after two
years), the general latent transition model can be specified in this way:
the progression of mild cognitive impairment (MCI) and early Alzheimers disease
(AD) (Liu et al., 2016). Recently, the ADNI database has been used in various
studies about Alzheimers disease. Data of participants in three traditional clinical
groups, which are NC (normal control), MCI (Mild cognitive Impairment) and AD
(Alzheimers disease), are available in ADNI database. The longitudinal data
performed in the latent transition model contain 1,879 participants from 2005 to
2014 who were examined at baseline time and with repeat visits every 6 months for
a period of up to 108 months.
In addition, there are three stages of ADNI including ADNI 1, ADNI GO and ADNI 2
[18]. As the earliest stage, ADNI1 was aimed to find out more accurate diagnose
method for detecting AD in the earliest or pre-diagnosis stage and define the
pathology using biological markers. The various biological biomarkers in ADNI
include existed brain-imaging techniques, such as PET (Positron Emission
Tomography) and MRI (Magnetic Resonance Imaging) for detecting early stage of AD
as well as a series tests including PET scans, lumbar punctures for CSF, blood tests,
neuropsychological tests and tests of psychiatric function for mood [17]. Then, the
data of these biomarkers are collected and analyzed for the progression of cognitive
decline as well as assisting researchers to develop the potential treatments. Later,
the second stage of ADNI GO was launched from June 2009 to 2011. Based on ADNI
1, ADNI GO aimed at developing standardized methods for clinical tests according to the previous
ADNI studies in order to have a better understanding of cognitive decline in the early stage of AD.
Then, ADNI2 as the third stage of ADNI started in 2011 and it mainly focus on comparing
cerebrospinal fluid and genetics biomarkers of those aged people who are not suffering from AD with
those who have mild symptoms of AD. The data employed in this study are from ADNI 1.
In this study, the demographics of participants must be considered for modeling the progression of
AD. The main risk factors for developing Alzheimers disease are age and gender [19]. Several
studies suggested that the incidence of the disease is higher in women than man which cannot be
simply attribute to the longer longevity of women but men and women have different pathogenic
mechanism for the progression of AD. [19,Cacciottolo M et al., 2016; Galen Buckwalter et
al., 1993) From Table 1, we observed significant differences between women and
men, which indicate the relevance of gender to studies of AD. Additionally, many
studies revealed that genes play an important role of Alzheimers progression.
Among all of the genetic risk factors, APOE4 alleles are the greatest genetic risk factor for
late-onset Alzheimers [20]. However, this doesnt mean that an individual will absolutely get
Alzheimers disease if he or she has one or two copies of APOE4, this just indicates increasing the
risk for developing the disease as well as lower the age of potential disease onset. Since some
scientific evidence exists to suggest that certain proposed Alzheimers prevention therapies may
work differently in people who carry at least one copy of the APOE4 gene, which indicates the
importance of the APOE4 gene, this gene should be considered as one of covariates for AD
progression modeling. Besides considering the demographics and genetic risk factors of the
participants, there are lots of other risk factors that are related to the AD, however, it should also
raise a concern that we might not have enough data from the ADNI dataset (table
**) to accurately specify the covariates effects in this complex modeling application
and that we are potentially over-fitted. In this study, the gender and the gene
APOE4 are the covariates for this modeling.
Biomarkers selection:
The disease progression model might be most effective with the pathologically
sensitive biomarkers that provide important avenues of research to enhance the
diagnosis of those individuals at risk for developing AD. Ideally, bio-markers should
be able to detect specific pathological features of AD neuropathology or have high
sensitivity for describing AD pathophysiological processes (Biagioni et al., 2011). As
we introduced before, the AD biomarkers for the pathophysiological process of AD in
the diagnostic criteria can be categorized into three groups: pathological, structural
or functional, and clinical. This ADNI dataset include CSF _ amyloid 42, tau as
pathological biomarkers indicating
pathology appears in the presymptomatic phase of AD. The FDG-PET and volume of
hippocampus as structural and functional biomarkers are included in our dataset.
Additionally, MMSE as one of biomarkers in clinical group (behavior, cognition and
function) in our dataset suggests the dementia with impairment and loss of function
in activities which usually appears in the prodeomal phase of AD.
In this study, the convergence of multi-states complex model for ADNI data was
adversely affected when too many biomarkers involved in modeling application.
Additionally, if data are inadequate for AD progression modeling, it might also raise
a concern for over-fitting. Considering these concerns, the following 3 biomarkers
were selected for use based on their sensitivity in assessing the progression of AD.
FDG: From figure ***, we can see that FDG as an indicator of synaptic dysfunction
and neurodegeneration in AD, suggests the hypo-metabolism in regional cerebral
appearing in the MCI stage and exacerbating in AD stage. In 2008, Mosconi L
implicated the brain hypo-metabolism is related to the progression of synaptic pathology in
AD (2008, Mosconi L).
Hippocampus: From the figure ***, we know that the decreasing of the hippocampal
volume appearing in the MCI stage and deteriorating in the AD stage.
\\
\\
Transition probability
The primary interest of this study is the pattern of progression of latent states of AD
in two year period. Interestingly, from the transition probability of latent AD states,
we can clearly see there are two profiles of AD progression and one was determined
by FDG-PET and another was led by the volume of hippocampus. The figure of
transition probability demonstrates the pattern of AD progression in 2 years, for
instance, if an individual has been classified in Normal state at the beginning, 2
years later, he or she has
change transit to H1
transit into F2. This transition pattern suggests few interactions between these two
profiles.
Two profiles:
From figure , compared with clinical results, the latent states from our model are
clearly distinct. Based on the distributions of FDG and hippocampus, we named the
six latent state as normal, F1, F2, H1, H2 and AD which F1 state represents the
hypo-metabolism in regional cerebral and F2 means the deterioration of hypometabolism than F1; while H1 implies the hippocampal abnormality and H2
suggests the worse abnormality in hippocampus than H1. Besides, from the figure
***, the density distributions of the latent states of FDG profile and Hippocampus
profile are clearly distinct which provides evidence of the existing of two progression
profiles.
Discussion
Two profiles:
1. Two profiles normal F1 f2 AD or normal H1 H2 and AD which advance our
understanding of AD:
The novelty of this study is these two profiles of the AD progression. Although
the exact mechanism for developing AD as well as triggers responsible for progressing to
advanced stage of disease, is still largely unknown, this study provides an advanced
understanding of the progression of AD by detecting the latent states of AD. Surprise, our model
revealed these two profiles. One is determined by FDG while another is by Hippocampus. It
implies the complexity of AD pathological progression. Specifically, our model reveals that some
patients have hypometabolism in regional cerebral but their volume of
hippocampus are still preserved while others with hippocampal atrophy but
dont have hypometabolism in cerebral. Recently, Hanseeuw B revealed that
cortical hypometabolism was observed in both A-MCI and A+ MCI whereas hippocampal
atrophy was mostly found in A+ MCI which implies that hippocampal atrophy is thus more
informative about A status than cortical hypometabolism ( 2016, Hanseeuw B). This finding
provided evidence to support that there is pre-symptomatic, amyloidmediated acceleration of hippocampal atrophy which suggesting the
hippocampal atrophy could be one of pre-symptomatic biomarkers of AD
progression (K. Abigail Andrews, 2016). Both of these studies provided evidence
implying the hypo-metabolism and hippocampal atrophy could happen in presymptomatic phase of AD progression.
From the transition probability, few interaction between these two profiles
suggests these two pattern of AD progression are almost independent from
each other which provides advanced information of the relationship of the
hippocampal atrophy and the hypo-metabolism in cerebral of AD progression.
In 2015, a study suggesting a different pathological mechanism in the
particular area of the brain may explain the two profiles of AD progression
since the hippocampal atrophy is more structural while the hypo-metabolism
of cerebral is more functional in AD progression (2015, Rodriguez-Oroz MC).
In our further studies, we should focus on pre-screen AD patients with presymptomatic biomarkers since they are critical in early detection and
diagnosis.
Transition probability:
1. Two profile pattern (no interaction)
2. Irreversible
Further research
1. Prescreen AD with presymptomatic biomarkers
2. Put more biomarkers
The primary clinical interest in this study is in the pattern of progression of latent
states of AD, such as the probability of transiting from normal control state to F
H+ state in two years. Interestingly, this outcome suggested that the AD
progression is not simply from lower to higher 12 disease states, but a complicated
system which illustrated two profiles of the progression. One of them was primarily
determined by FDG-PET and the other by the volume of hippocampus. Compared
with the three traditional diagnoses states, this six states latent transition model
provided more details about the pattern of intermediary transitions between states.
These results give the progression profiles of FDG-PET and the volume of
hippocampus. In this AD progression model for two-year period, the FDG, as one of
the sensitive biomarkers for earliest clinically detectable evidence for brain
pathological changes, appeared to be abnormal earlier than the volume of
hippocampus since the decrease of FDG from normal state to F H+ in twoyear
period is dramatic and close to the FDG value of final AD state(Figure 2). This
pattern indicated that the FDG biomarker has potential to be a better biomarker for
detecting the AD in pre-symptomatic phase and contribute the preclinical screening
for treatment development since the abnormality appears earlier in FDG than the
volume of hippocampus. The transition probability in two years was estimated and
reported in Figure 3, which indicate AD irreversible. Two patterns of AD progression
emerge in this six-states latent transition model. The latent transition model
suggested six states of disease progression and two different pathological profiles.
One progression profile was mainly determined by the biomarker of FDG-PET and
the other by the volume of Hippocampus.
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