Longitudinal studies, where data on study subjects are collected over time, is increasingly involving multivariate longitudinal responses. Frequently, the heterogeneity observed in a multivariate longitudinal response can be attributed to underlying unobserved disease states in addition to any between-subject differences. We propose modeling such disease states using a hidden Markov model (HMM) approach and expand upon previous work, which incorporated random effects into HMMs for the analysis of univariate longitudinal data, to the setting of a multivariate longitudinal response. Multivariate longitudinal data are modeled jointly using separate but correlated random effects between longitudinal responses of mixed data types in addition to a shared underlying hidden process. We use a computationally efficient Bayesian approach via Markov chain Monte Carlo (MCMC) to fit such models. We apply this methodology to bivariate longitudinal response data from a smoking cessation clinical trial. Under these models, we examine how to incorporate a treatment effect on the disease states, as well as develop methods to classify observations by disease state and to attempt to understand patient dropout. Simulation studies were performed to evaluate the properties of such models and their applications under a variety of realistic situations.

Longitudinal studies, where data on study subjects are collected over time, is increasingly involving multivariate longitudinal responses. Frequently, the heterogeneity observed in a multivariate longitudinal response can be attributed to underlying unobserved disease states in addition to any between-subject differences. We propose modeling such disease states using a hidden Markov model (HMM) approach and expand upon previous work, which incorporated random effects into HMMs for the analysis of univariate longitudinal data, to the setting of a multivariate longitudinal response. Multivariate longitudinal data are modeled jointly using separate but correlated random effects between longitudinal responses of mixed data types in addition to a shared underlying hidden process. We use a computationally efficient Bayesian approach via Markov chain Monte Carlo (MCMC) to fit such models. We apply this methodology to bivariate longitudinal response data from a smoking cessation clinical trial. Under these models, we examine how to incorporate a treatment effect on the disease states, as well as develop methods to classify observations by disease state and to attempt to understand patient dropout. Simulation studies were performed to evaluate the properties of such models and their applications under a variety of realistic situations.

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Le but de ce travail a été de proposer des méthodes d'inférence pour décrire l'histoire naturelle de la phase pré-diagnostic de la démence. Durant celle-ci, qui dure une quinzaine d'années, les trajectoires de déclin cognitif sont non linéaires et hétérogènes entre les sujets. Pour ces raisons, nous avons choisi un modèle à changement de pente aléatoire pour les décrire. Une première partie de ce travail a consisté à proposer une procédure de test pour l'existence d'un changement de pente aléatoire. En effet, dans certaines sous-populations, le déclin cognitif semble lisse et la question de l'existence même d'un changement de pente se pose. Cette question présente un défi méthodologique en raison de la non-identifiabilité de certains paramètres sous l'hypothèse nulle rendant les tests standards inutiles. Nous avons proposé un supremum score test pour répondre à cette question. Une seconde partie du travail concernait l'ordre temporel du temps de changement entre plusieurs marqueurs. La démence est une maladie multidimensionnelle et plusieurs dimensions de la cognition sont affectées. Des schémas hypothétiques existent pour décrire l'histoire naturelle de la démence mais n'ont pas été éprouvés sur données réelles. Comparer le temps de changement de différents marqueurs mesurant différentes fonctions cognitives permet d'éclairer ces hypothèses. Dans cet esprit, nous proposons un modèle bivarié à changement de pente aléatoire permettant de comparer les temps de changement de deux marqueurs, potentiellement non gaussiens. Les méthodes proposées ont été évaluées sur simulations et appliquées sur des données issues de deux cohortes françaises. Enfin, nous discutons les limites de ces deux modèles qui se concentrent sur une accélération tardive du déclin cognitif précédant le diagnostic de démence et nous proposons un modèle alternatif qui estime plutôt une date de décrochage entre cas et non-cas. / The aim of this work was to propose inferential methods to describe natural history of the pre-diagnosis phase of dementia. During this phase, which can last around fifteen years, the cognitive decline trajectories are nonlinear and heterogeneous between subjects. Because heterogeneity and nonlinearity, we chose a random changepoint mixed model to describe these trajectories. A first part of this work was to propose a testing procedure to assess the existence of a random changepoint. Indeed, in some subpopulations, the cognitive decline seems smooth and the question of the existence of a changepoint itself araises. This question is methodologically challenging because of identifiability issues on some parameters under the null hypothesis that makes standard tests useless. We proposed a supremum score test to answer this question. A second part of this work was the comparison of the temporal order of different markers changepoint. Dementia is a multidimensional disease where different dimensions of the cognition are affected. Hypothetic cascade models exist for describing this natural history but have not been evaluated on real data. Comparing change over time of different markers measuring different cognitive functions gives precious insight on this hypothesis. In this spirit, we propose a bivariate random changepoint model allowing proper comparison of the time of change of two cognitive markers, potentially non Gaussian. The proposed methodologies were evaluated on simulation studies and applied on real data from two French cohorts. Finally, we discussed the limitations of the two models we used that focused on the late acceleration of the cognitive decline before dementia diagnosis and we proposed an alternative model that estimates the time of differentiation between cases and non-cases.