The presenters propose a framework for identifying non-English speaking, immigrant patients with reported neurocognitive impairment for which motivation for U.S. Citizenship Exam Exception (N-648) is concealed.  We aspire to broaden neurologists’ perspective and skill set to recognize potential patients with external incentive to seek Medical Exception based on Neurocognitive Impairment.

Many neurologists are unfamiliar with the multicultural, legal and family systems variables that can reveal the hidden agenda that some patients have when they present with “memory loss,” despite often being the first medical specialists consulted to evaluate cognitive impairment. Such dynamics present a challenge for the neurologist responding to these complex referrals in diagnostic determination and the decision to refer to neuropsychology.

Because neuropsychologists require support from empirical data and collateral report to determine true cognitive impairment, unfamiliarity with the N-648 phenomenon results in an inaccurate diagnosis of dementia which the neuropsychologist must address.

Neurocognitive profiles of five patients and their collateral histories will be presented to illustrate incongruencies that can signal feigned impairment for N-648 Exception.   

We will propose a framework for recognizing patients that are eligible based on medical history and documentation, imaging, and neurocognitive status in light of the ever-growing immigrant influx into the U.S. seeking naturalization.

Ethnocultural factors (e.g., language, political backdrop, level of acculturation, migration history) appear to influence the patients' motivation to seek a neuropsychology referral from neurology, as evidenced by incongruencies between objective psychometric measures and collateral report.

It is these authors' aim to familiarize neurologists with the N-648 phenomenon and provide them with a working “checklist” that highlights aforementioned ethnocultural factors and guides identification of potential patients seeking N-648 Exception. We hope that this will help distinguish patients with true cognitive impairment from those whose neurocognitive profile may be a clinical masquerade.