Older Immigrants Requesting Citizenship Test Exemption: Evaluations to Support Medical Certification Kevin Foley, MD1,2, Karen Bugg, RN, LMSW1 1. Mercy Health Saint Mary’s, Grand Rapids MI 2. Department of Family Medicine, College of Human Medicine, Michigan State University, East Lansing, MI Abstract Background Results Background: U.S. immigrants age ≥ 65 granted legal permanent resident (LPR) status reached 55,628 in 2012. If citizenship (naturalization) is achieved within 7 years, Social Security income and other government benefits continue. To obtain citizenship, LPRs must pass English and Civics tests. Older LPRs are at risk for dementia and psychiatric disorders that may impair their ability to learn. If certified as being unable to learn by physicians/psychologists on Form N-648 (Medical Certification for Disability Exceptions), older LPRs may be granted a naturalization test exemption (NTE) by the Department of Homeland Security provided that adequate documentation is submitted in an acceptable format. The examiner must verify the existence of a medically determinable impairment of ≥12 months duration through valid clinical and diagnostic means, and describe its hindrance to learning. Diagnoses based solely on clinical interview may be adequate if the process is thoroughly explained on the form. Cognitive assessments in older LPRs with limited English proficiency (LEP) are challenging and require time. Brief exams may misidentify those with the ability to learn. The medical literature offers no guidance to clinicians as to how a NTE should be conducted.  Methods: A retrospective medical record review was performed for 13 LPRs age ≥ 60 who presented to a memory clinic requesting a NTE. Records were abstracted for demographic data (age, gender, ethnicity) and clinical information (examination type, diagnostic testing, diagnosis, assessment outcome).  Results: Mean age of LPRs was 72.2 years (range 63-85, 60% female). Birth countries included Bosnia (5), Cuba (5), Somalia (1), Iran (1), and the Dominican Republic (1). Post traumatic stress disorder (PTSD) (6) causing learning impairment was uniformly diagnosed among Bosnian and Somali LPRs through a clinical interview or neuropsychological testing. Clinical examination, diagnostic testing, and neuropsychological evaluation identified 4 LPRs with dementia or a medical disorder to support an exemption and 3 LPRs with no objective evidence of learning impairment.  Conclusions: A comprehensive evaluation may be necessary to support a request for NTE by an older immigrant with LEP, unless PTSD is clinically suspected. Clinicians will have appropriate information to support the NTE request, make suitable referrals, and prevent delay in the applicant's citizenship process. (No funding for this research to disclose.) Approximately 650,000 naturalizations occur annually; during 2012, 103,231 adults age > 60 (53% male) became U.S. citizens.1 Immigrants granted legal permanent resident (LPR) status may become U.S. citizens if specific requirements are met, including passing a citizenship (naturalization) examination.2 LPRs must be able to read, speak, and write basic English and have knowledge of U.S. history, civics, and government.2 Older LPRs, who may have limited English proficiency (LEP), are at risk for dementia and psychiatric disorders that can impair their ability to learn and acquire this knowledge. An exemption is allowed for LPRs who have evidence of a medically determinable physical or mental impairment that severely impairs learning ability.3 Documentation for this exemption request must be provided by a licensed physician or a psychologist in an approved format that must clearly explain the causal connection between the applicant’s medical or psychiatric condition and its impact on learning English and civics.4 Cognitive assessments in older LPRs with LEP are challenging to perform and often require additional time. The medical literature offers no guidance to clinicians in how to perform cognitive assessments on LPRs for the purpose of supporting a naturalization test exemption (NTE) request. Under penalty of perjury, both the applicant and the medical professional must attest that all of the information submitted is true and correct.3 To formulate specific evaluation recommendations, this study involved a retrospective categorization of the clinical approaches used and results of assessments performed on LPRs presenting to a memory disorders clinic who requested a NTE. Review of 72 medical records identified 13 subjects who met all inclusion criteria. Age (yrs) Gender Birth Country Education (yrs) Evaluation Type Clinical Diagnosis Neuropsychological Assessment Diagnosis Exemption Request Outcome 78 F Iran Clinical Examination with Diagnostic Tests Dementia NOS Alzheimer’s Dementia Granted 84 M Cuba 11 Lewy Body Dementia Not ordered 65 Dominican Republic 2 Severe CHF and COPD Bosnia Diagnostic Interview PTSD 12 87 3 Vascular Dementia 71 Cognitive Disorder NOS No diagnosis (suboptimal effort) Denied 68 10 74 63 Somalia 81 6 Aging Associated Cognitive Impairment 75 No diagnosis (suboptimal effort) 66 NOS – Not Otherwise Specified PTSD – Post Traumatic Stress Disorder Conclusions A comprehensive clinical examination with additional diagnostic tests, including a neuropsychological assessment, may be necessary to fully support a request for a NTE. If PTSD is clinically suspected, a diagnostic interview alone may be sufficient to support the NTE request. Further research on means to conduct NTE assessments for LPRs with LEP is warranted. Methods Eligible subject medical records from 2004-2013 for retrospective review were identified using a hospital database search. Inclusion criteria: 1) Male or female adults, age 60-89, seen in the Mercy Health Saint Mary’s memory disorders clinic for a cognitive assessment, who requested documentation to support a NTE on Form N-648. 2) LEP, defined as a need for medical interpretation services during the assessment (patient/family request or determined by a clinic appointment scheduler). Data abstracted from medical records: demographic information, evaluation type (diagnostic interview or clinical examination with additional diagnostic tests), neuropsychological assessment results (when ordered), diagnoses, and outcome of NTE request. Mercy Health Saint Mary’s Institutional Review Board approved this project and deemed it exempt from full review. Project Overview References Primary objective: to describe our experience in conducting citizenship test exemption assessments among older adults with LEP through a retrospective medical record review. Secondary objective: to formulate specific diagnostic strategy recommendations to support necessary documentation for test exemption requests by older patients who have medical or psychiatric conditions that impair learning of English and civics. 2012 Yearbook of Immigration Statistics. Office of Immigration Statistics, U.S. Department of Homeland Security Web Site. https://www.dhs.gov/yearbook-immigration-statistics-2012-naturalizations. Monger M, Yankay J: U.S. Legal Permanent Residents: 2012. Office of Immigration Statistics, U.S. Department of Homeland Security Web Site. https://www.dhs.gov/yearbook-immigration-statistics-2012- naturalizations. Form N-648. Medical Certification for Disability Exceptions. U.S. Department of Homeland Security Web Site. http://www.uscis.gov/sites/default/files/files/form/n-648.pdf. USCIS Policy Manual. U.S. Citizenship and Immigration Services. U.S. Department of Homeland Security Website. http://www.uscis.gov/policymanual/HTML/PolicyManual.html.