A research Project synopsis on

CORRELATION BETWEEN MOCA AND MMSE FOR THE

ASSESSMENT OF COGNITIVE FUNCTIONING IN CHRONIC
SCHIZOPHRENIC PATIENTS.

Project for Observational Internship 2021

By Diya Gautam
9 February 2022

Under the guidance of

Dr Paramjeet Singh &
Dr Gunjan Solanki &
Dr Jaishree Jain

Department of Psychiatry,
S.M.S. Medical College, Jaipur
Introduction

As you know Schizophrenia is characterized by general impairment distortion in thinking and

perception. They are defined by abnormalities in one or more of the following five domains:
delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal
motor behavior including catatonia), and negative symptoms(DSM-5). This distortion affects
most basic functions that a normal individual possesses like uniqueness, a sense of self-direction,
invisibility. Over the past 20 years, there has been increased recognition of the importance of
cognitive impairments in schizophrenia (Sharma and Antonova, 2003). Modern antipsychotics
and psychosocial treatment programs have been effective in moderating symptoms and reducing
the rate of relapses; most schizophrenic patients do not function well outside structured, routine
settings. Outcomes other than symptom improvement and relapse prevention have not been well
documented (Lehman, 1995; Hogarty & Flesher, 1999).
The symptoms associated with schizophrenia spectrum disorders fall into four categories:
positive symptoms, psychomotor abnormalities, cognitive symptoms, and negative symptoms

Positive Symptoms
Positive symptoms associated with schizophrenia spectrum disorders involve delusions,
hallucinations, disordered thinking, incoherent communication, and bizarre behavior e, D. D. W.
S., 2022). One positive symptom should be present in the active or acute phase of schizophrenia
to diagnose it. The most common positive symptoms of schizophrenia are delusions and
hallucinations.

Delusion
A person with delusion has a false perception of beliefs that lacks evidence and reality. A person
experiencing these symptoms cannot distinguish between his private thoughts and external
reality. In schizophrenia, the content of delusional beliefs often contains contradictions, and the
relationship between delusional beliefs and any action that might flow from them is
unpredictable (Sarason, B. R. 2004). There are many types of bizarre delusions, For instance, one
may believe everyone can hear their thoughts or one may try to insert or remove his/her
thoughts. Those with paranoid ideation often have high levels of anxiety and worry, as well as
angry reactions to perceived persecution (Startup, Freeman, & Garety, 2006). One can also feel
like everything that's happening in this world involves them. Delusions can produce strong
emotional reactions such as fear, depression, or anger. Those with persecutory delusions may
respond to perceived threats by leaving “dangerous” situations, avoiding areas where they might
be attacked, or becoming more vigilant (Sue, D. D. W. S., 2022).

Hallucinations
The personal, cultural, and clinical significance of hallucinations has changed in the 200 years
since they were defined by Esquirol as “the intimate conviction of actually perceiving a sensation
for which there is no external object”( ESQUIROL, E., 1845). Hallucinations are the perception
of non-existential stimuli. It can be a combination of different sensory stimuli or single sensory
stimuli, which includes auditory hallucinations, visual hallucinations, olfactory hallucination,
tactile hallucination, and gustatory hallucination. Auditory and visual hallucinations are most
common among them. Brain activity during hallucinations has been investigated using scanning
techniques. The results showed that, during auditory hallucinations, the blood flow in Broca’s
area (the brain’s speech concentrates significantly greater during the time the hallucination was
occurring than when it was not (McGuire et al., 1993). Researchers also found that activity
decreased in Wernicke’s area (the brain’s hearing cencentreuring the hallucination (Sarason, I.
G., & Sarason, B. R., 2004b).

Negative Symptoms
Negative symptoms of schizophrenia are associated with an inability or decreased ability to
initiate actions or speech, express emotions, or feel pleasure (Barch, 2013). They are common in
schizophrenic persons. They don’t feel motivated and have flat speech, they are generally
associated with poor social functioning. As (DSM-5) stated these symptoms as Two negative
symptoms that are particularly prominent in schizophrenia: diminished emotional expression and
avolition. Diminished emotional expression includes reductions in the expression of emotions in
the face, eye contact, intonation of speech (prosody), and movements of the hand, head, and face
that normally give an emotional emphasis to speech. Avolition is a decrease in motivated
self-initiated purposeful activities. The individual may sit for long periods and show little interest
in participating in work or social activities. Other negative symptoms include alogia, anhedonia,
and asociality. Alogia is manifested by diminished speech output. Anhedonia is the decreased
ability to experience pleasure from positive stimuli or a degradation in the recollection of
pleasure previously experienced. Asociality refers to the apparent lack of interest in social
interactions and may be associated with avolition, but it can also be a manifestation of limited
opportunities for social interactions.

Cognitive Impairment
Distorted thinking, speech, communication are the core features of impairment in the cognition
of a schizophrenic person. The domains of these impairments may include sensory abilities,
thinking, thought process, memory, motor skill, abstract skills. It has also been shown that this
cognitive deficit has not only been described in long-standing schizophrenic patients but is also
present in patients with a first psychotic episode, in remission, in patients without antipsychotic
medication, and even in studies in high-risk subjects and close relatives and healthy patients with
schizophrenia. . A person with cognitive deficits impairs with motivation, insight about one's
illness and treatment, and they also negatively affect the therapeutic alliance (Susmita Halder, &
Akash Kumar Mahato., 2015)

“It is estimated that among 61–78% of patients with schizophrenia manifest a significant level of
cognitive deficit reaching between 1 and 2 standard deviations below the control groups of the
same age. These cognitive deficits seem independent of positive symptoms and are maintained
throughout the disease” (García-Laredo, E., 2018).

Memory, Verbal Learning, Attention, and executive functions

Patients with schizophrenia disorder have been shown a cognitive decline at both chronic and
follow-up diadiagnoseshese patients generally have psychosis and decline in memory, recall
memory, attention, and verbal abilities.
The characteristic symptoms of the attention deficits include perseveration, over switching, and
inability to ignore irrelevant stimuli. Attentional skills are disrupted by a wide variety of causes
and attention is a critical underlying component of many cognitive functions.
A journal (Schizophrenia Spectrum and Other Psychotic Disorders., 2013), said that the most
common deficit cognitive ability is in memory. This type of impairment is usually long-term,
debilitating, and difficult to treat. they found it hard to recall, recognize or even learn both visual
and verbal materials. An increasing amount of research has investigated memory deficits in
schizophrenia and studies have documented greater impairments in verbal memory than in other
cognitive functions and these deficits do not appear to be accounted for by abstraction or
attention (Gold et al., 1992; Saykin et al.1994).
The other one is executive functioning which includes the ability to plan for the future, goal,
task-oriented. Schizophrenic patients have these varying cognitive impairments.

Can we treat cognitive impairments?

Antipsychotic medications have been available for a long time but they can only decline the
psychotic features, they cannot cure the disease. These medications may vary among individuals
depending on the level of severity and side effects. Newer antipsychotics including paliperidone,
lurasidone, aripiprazole, ziprasidone, and BL-1020, reported benefits in patients with
schizophrenia. Several studies have reported that N-methyl-d-aspartate glutamate receptor
(NMDAR) enhancers improved cognitive function in patients with chronic schizophrenia (Hsu,
W. Y., Lane, H. Y., & Lin, C. H. 2018).
Psychotherapies may focus on their past and present life events. By talking to trained
professionals they can gradually understand their problems. It won’t be a substitute for
antipsychotic drugs but can help them in developing coping strategies and problem-oriented
skills. They can help them get behavioral changes, help them maintain good self-care.
Physiotherapy and occupational therapy can also be used to maintain cognitive impairments
and help in better living.
Rehabilitation can also help them in getting job training, problem-solving skills, vocational
training, etc. Cognitive rehabilitation is a form of intervention in which a series of procedures are
applied by a trained practitioner to retain or alleviate problems due to deficits in underlying
cognitive functions (Sohlberg and Mateer, 1989)

Literature Review
As many studies have been done on the declining cognitive impairments in schizophrenia. Since
impairment in cognitions is the core symptom of schizophrenic patients. Cognitive impairments
may consist of the inability to recall, inattention, memory as seen in Erkan Alkan, Geoff Davies
& Simon L. Evans' article in which he talked about the Cognitive impairment in schizophrenia:
relationships with cortical thickness in frontotemporal regions, and dissociability from symptom
severity. Their sample was 70 SZH and 72 age and gender-matched healthy controls (provided
by the Center of Biomedical Research Excellence (COBRE). Finding links with no symptom
severity were observed in these regions, suggesting these relationships are dissociable from
underlying psychotic symptomatology.

Also, Susmita Halder, Akash Kumar Mahato studied Cognitive Impairment in Schizophrenia: An
Overview of Assessment and Management. In 2006 Christopher R Bowie and Philip D Harvey
studied impairments in cognitive functions in schizophrenia and they focus on can we cure it.

David J.MoorePh.D.aBarton W.Palmer Ph.D.Dilip V.JesteM.D. published an article in 2004 in

The American Journal of Geriatric Psychiatry about Use of the Mini-Mental State Exam in
Middle-Aged and Older Outpatients With Schizophrenia: Cognitive Impairment and Its
Associations. The results were that MMSE was successful in dictating cognitive decline in
schizophrenia but they lacked sample size.

Another study was done on CORRELATION BETWEEN MOCA AND MMSE FOR THE
ASSESSMENT OF COGNITION IN SCHIZOPHRENIA by Saida Fisekovic, Amra Memic, and
Alma Pasalic. Their findings were that MOCA is more convenient in detecting true positives but
it is imprecise in the detection of true negative findings. A mild cognitive impairment study was
also done on the Chinese middle-aged and older population by (“Xiaofang Jia,1 Zhihong Wang,1
Feifei Huang,1 Chang Su,1 Wenwen Du,1 Hongru Jiang,1 Huijun Wang,1 Jiaqi Wang,2,
Fangjun Wang,3 Weiwu Su,4 Huifang Xiao,5 Yanxin Wang,6 20and Bing Zhang Corresponding
author in 2021”) there topic was A comparison of the Mini-Mental State Examination (MMSE)
with the Montreal Cognitive Assessment (MoCA) for mild cognitive impairment screening in
Chinese middle-aged and older population: a cross-sectional study. Their conclusion was
“MoCA is a better measure of cognitive function due to lack of ceiling effect and with good
detection of cognitive heterogeneity. MCI prevalence is higher using MoCA compared to
MMSE. Both tools identify concordantly modifiable factors for MCI, which provide important
evidence for establishing intervention measures”

Rationale of study
As cognitive impairments are the main features in chronic schizophrenic patients. Cognitive
impairment may include a decline in memory recall, poor motor movements, loss of short and
long-term memory, attention, distorted speech, communication problems. Cognitive impairments
have been shown symptoms of different diseases like depression, diabetes, Parkinson's disease,
autism, Alzheimer's, and schizophrenia. It has been studied that this cognitive deficit has not
only been described in long-standing schizophrenic patients but is also present in patients with a
first psychotic episode, in remission, in patients without antipsychotic medication, and even in
studies in high-risk subjects and close relatives and healthy patients with schizophrenia. A person
with cognitive deficits impairs motivation, insight about one's illness and treatment, and they
also negatively affect the therapeutic alliance.

But this doesn't mean there is no cure. Antipsychotic drugs given to patients apart from this
psychotherapy can be used side by side to help them in differentiating between their thoughts and
reality. Self-help groups, educating their family members, physiotherapy, music therapy, and
vocational therapy have also been shown in declining these cognitive impairments.

There are many tools to screen cognitive impairments like -Abbreviated Mental Test Score,
Clock drawing, Mini-Cog, 6-CIT, Test Your Memory, General Practitioner assessment of
Cognition, Memory Impairment Screen, Mini-Mental State Examination.
Research has been done on the causes of cognitive impairment in schizophrenics and on the
treatments. Many screening tools have been tested. There are several tests to conduct and based
on research MOCA and MMSE are considered very convenient tests. But still, there is no
significant research on which test is best- MOCA or MMSE on declining cognitive impairments
in chronic schizophrenic patients in Jaipur.

This paper will present the comparison of MOCA and MMSE tests and which test is best situated
on declining cognitive impairments in chronic schizophrenic patients in the Jaipur region.

Methodology

Research Problem
This paper presents the Correlation between MOCA and MMSE for the assessment of cognitive
functioning in chronic schizophrenic patients.

Objective
To study the correlation between MoCA and MMSE study that there will be significant
correlation between MOCA and MMSe.

Hypothesis
There will be significant correlation between MOCA and MMSE tests

Methods
MOCA and MMSE tests will be administered to chronic schizophrenic patients both male and
female of age above 30 years. The samples will be from Rajasthan, Jaipur region. Urban and
suburban neighborhoods within the cities and townships and villages within the counties were
selected randomly. The MMSE and MoCA scores for each participant were matched and
compared using the non-parametric test.

Cognitive Assessment
All the participants will undergo cognitive assessment using The Montreal Cognitive Assessment
and Mini-Mental State Exam (MMSE). Both the instruments are valid and reliable. Instructions
will be given. MMSE and MoCA were conducted strictly face to face following the guidelines
and protocols by trained investigators and were completed during 5–10 min and 10–15 min,
respectively.

The MMSE is a 30-point questionnaire used extensively in clinical and research settings to
measure cognitive impairment, including simple tasks in a number of areas: the test of time and
place, the repeating lists of words, arithmetic such as serial subtractions of seven, language use
and comprehension, and basic motor skills. The MoCA is another 30-point test covering eight
cognitive domains, and details on the specific MoCA items had been introduced by Nasreddine
et al.]. The cultural and linguistic modifications of the MoCA Beijing version we used from the
original English version were also concretely described.
Here is the difference between the Mini-Mental State Examination (MMSE) with the Montreal
Cognitive Assessment (MoCA)

Domains MMSE MoCA

Items/maximum scores Items/maximum scores

Orientation Orientation to time and Orientation to time and

place/10 place/6

Calculation Serial 7 subtractions/5 Serial 7 subtractions/3

Naming Naming (pencil, cellphone)/2 Naming (lion, giraffe,

camel)/3
 Repetition 1 short sentence/1 2 longer sentences/2

Visuoconstructional skills Copy intersecting Copy cube/1

pentagons/1 Draw clock face/3

Registration Repeat 3 words/3

Recall Recall 3 words/3 Recall 5 words/5

Writing Write a sentence/1

Attention Vigilance test for number

‘1’/1

Sampling
Sample size- 100
Sampling method- purposive Sampling
Locale- Jaipur

Variables
Independent variable- MoCa test and MMSe test, Cognitive impairment
Dependent variable- Schizophrenia

Inclusion Criteria
Age above 30 years
Gender: male and female
Diagnosed with Schizophrenia for more than 3 years
Should have cognitive impairment
Exclusion Criteria
Age below 30 years
Pregnant women

Tools To Be Used
Mini-Mental State Examination (MMSE)
Montreal Cognitive Assessment (MoCA)

PROCEDURE
The study will be conducted in two phases.
o Phase I: based on criteria of inclusion and exclusion. Sample of study will be collected
for data collection.
o Phase II: tools of the study will be administered on the samples.

Statistical Analysis
Mean
SD
Correlation
Regression
Moderation

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