traditionally , the emotional needs of dementia family caregivers are conceptualized with the transactional model of stress and coping ( lazarus and folkman , 1984 ; pearlin et al . , 
 1990 ) . in this model ,
the focus is specifically on the emotion of stress , with emphasis on improving coping skills and lowering stress level .
this has translated into caregiver services like disease education , skills training , stress management and respite care .
however , stress is only one of the emotions experienced by caregivers , and there are a complex range of other emotions , such as guilt , denial , sadness and anger . from the recent evidence , this whole array of emotions can be better understood using the concept of predeath grief ( blandin and pepin , 2015 ) .
predeath grief is the emotional response as dementia family caregivers mourn for the psychologically absent patient and anticipate impending losses ( blandin and pepin , 2015 ) .
it is prevalent among dementia caregivers ( chan et al . , 2013 ) and can be more overwhelming than handson care issues ( frank , 2007 ) .
caregivers who do not recognize the presence of predeath grief tend to deny the losses they experienced and attempt to control the uncontrollable progression of dementia .
they become more paternalistic in their communication with the patients and more authoritarian in making decisions related to the patients .
such behaviours create inequity in the dyadic patient  caregiver relationship , with the caregivers feeling more helpless and the patients losing the sense of autonomy ( piiparinen and whitlatch , 2011 ) . with this understanding
, it is not surprising that predeath grief has been linked to negative consequences like caregiver burden ( holley and mast , 2009 ) , caregiver depression ( sanders and adams , 2005 ; chan et al . , 
 2013 ) and
caregivers ' desire to institutionalize the patient prematurely ( walker et al . , 1995 ) .
however , the published literature on predeath grief is derived primarily from the caucasian population ( chan et al . , 2013 ) . because the expression of grief varies with culture ( eisenbruch , 1984 )
this study investigates the existence ( primary aim ) and the characteristics ( exploratory aim ) of predeath grief in a multiethnic asian population using a wellestablished predeath grief scale  the marwit  meuser caregiver grief inventory ( mmcgi ) .
ethical approval was obtained from the domain specific review board of national healthcare group , singapore .
the following inclusion criteria were used : ( i ) spouses or children of patient with dementia ; ( ii ) caring for a patient with dementia not residing in nursing home ; ( iii ) able to read in english ; and ( iv ) aged at least 21  years .
the other scales of related construct , such as prolonged grief scale ( pg12 ) , zarit burden interview ( zbi ) and centre for epidemiologic studies depression scale ( cesd ) , were also included to contrast with mmcgi .
meuser caregiver grief inventory is a predeath grief scale developed empirically from extensive qualitative interview of dementia caregivers ( marwit and meuser , 2002 ) .
its 50 items are assessed through 5point scales and summed to generate a total score and three subscale scores corresponding to the different dimensions of loss  personal sacrifice burden , heartfelt sadness and longing , and worry and felt isolation . in the original us study ( marwit and meuser , 2002 ) , mmcgi showed high internal consistency reliability , with cronbach 's alpha ranging from 0.90 to 0.96 .
it also had good construct validity , with strong correlation with anticipatory grief scale ( pearson 's correlation coefficient , r  =  0.798 ) . meanwhile , personal sacrifice burden subscale correlated with caregiver strain index ( r  =  0.730 ) , heartfelt sadness and longing subscale with anticipatory grief scale ( r  =  0.666 ) and worry and felt isolation subscale with wellbeing scale ( r  =  0.718 ) .
the authors of mmcgi proposed using one standard deviation above the normative mean of a population to indicate high predeath grief and a need for further interventions . in the us population
, this translates to cutoff scores of > 175 for mmcgi , > 68 for personal sacrifice burden subscale , > 59 for heartfelt sadness and longing subscale and > 52 for worry and felt isolation subscale .
such normative values were not available for the singapore population at the time of this study .
prolonged grief scale is a 12item predeath grief scale for caregivers modified from a postdeath grief scale , the inventory of complicated grief .
it is based on the diagnostic criteria of prolonged grief disorder proposed for icd11 ( prigerson et al . , 2009 ) .
its first 11 items are rated on 5point scales and summed to produce a quantifiable total score , while item 12 is scored dichotomously for the absence or presence of sociooccupational dysfunction .
it assesses the perceived burden experienced by caregivers of older persons ( zarit et al . , 1980 ) .
zbi has five domains  burden in the relationship , emotional wellbeing , social and family life , finances and loss of control over one 's life ( rankin et al . , 1994 ) .
zbi has been validated in singapore ( seng et al . , 2010 ) , with good reliability and construct validity .
centre for epidemiologic studies depression scale is a 20item depression scale , assessed through 4point scales .
its four domains are depressed affect , positive affect , somatic symptoms and interpersonal problems ( radloff , 1977 ) . cesd was previously validated in singapore ( stahl et al . , 2008 ) , with cronbach 's alpha of 0.700.79 and diagnostic performance of 6482% .
the three dementia severities in the revised third edition of diagnostic and statistical manual of mental disorders ( american psychiatric association , 1987 ) were used as a brief measure of dementia staging . from the three options , participants chose the description that best described the patient with dementia  still capable of independent living ( mild stage ) , needs some assistance with daily living ( moderate stage ) or needs roundtheclock supervision ( severe stage ) .
this brief measure was previously shown to have reasonable agreement with clinical dementia rating scale (   =  0.560.6 ) ( forsell et al . , 1992 ; juva et al . ,
if predeath grief exists in the asian context ( primary aim ) , it should be measurable on mmcgi with high internal consistency reliability and with convergent and discriminant validities consistent with the original caucasian constructs ( marwit and meuser , 2002 ) .
we had four hypotheses regarding convergent validity : 
 mmcgi measures the experience of predeath grief .
therefore , it should show stronger correlation with another predeath grief scale , pg12 , than with zbi or cesd.personal sacrifice burden subscale captures the experience of individual losses due to caregiving .
it resembles caregiver burden measured by zbi and should correlate stronger with zbi than with pg12 or cesd.worry and felt isolation subscale measures the feelings of losing connection with others .
it is a feature of grief reaction and should correlate stronger with pg12 than with zbi or cesd.heartfelt sadness and longing subscale resembles the traditional concepts of grief , that is , one 's intrapersonal reactions to lost relationship .
therefore , it should show stronger correlation with another predeath grief scale , pg12 , than with zbi or cesd .
it resembles caregiver burden measured by zbi and should correlate stronger with zbi than with pg12 or cesd .
it is a feature of grief reaction and should correlate stronger with pg12 than with zbi or cesd .
heartfelt sadness and longing subscale resembles the traditional concepts of grief , that is , one 's intrapersonal reactions to lost relationship . hence , it should correlate stronger with pg12 than with zbi or cesd .
we made two hypotheses regarding discriminant validity : 
 heartfelt sadness and longing subscale should correlate poorer with depression scale cesd , consistent with ample evidence demonstrating the difference between grief and depression ( prigerson et al .
, 2009).mmcgi should correlate poorly with finances subscale of zbi and positive affect subscale of cesd , because they are distinctly different constructs . 
 
heartfelt sadness and longing subscale should correlate poorer with depression scale cesd , consistent with ample evidence demonstrating the difference between grief and depression ( prigerson et al .
mmcgi should correlate poorly with finances subscale of zbi and positive affect subscale of cesd , because they are distinctly different constructs .
first , linear regression was performed , with mmcgi as dependent variable , to identify factors associated with predeath grief .
all variables with p    0.075 in univariate regression were entered into multivariate regression , and variables with p  >  0.05 in multivariate regression were removed through stepwise backward selections .
second , the mean scores of mmcgi and its subscales were compared with those from the original us study ( marwit and meuser , 2002 ) using onesample ttest .
we calculated the sample size using bonett and wright 's formulas ( bonett and wright , 2000 , 2015 ) , setting the 95% confidence interval width at 0.2 .
referencing to the original study ( marwit and meuser , 2002 ) , we expected the cronbach 's alpha of mmcgi to approximate 0.90 , corresponding to a minimum sample size of 11 ; spearman 's correlation coefficient between mmcgi and pg12 should approximate 0.8 , corresponding to a minimum sample size of 72 .
ethical approval was obtained from the domain specific review board of national healthcare group , singapore .
the following inclusion criteria were used : ( i ) spouses or children of patient with dementia ; ( ii ) caring for a patient with dementia not residing in nursing home ; ( iii ) able to read in english ; and ( iv ) aged at least 21  years .
the other scales of related construct , such as prolonged grief scale ( pg12 ) , zarit burden interview ( zbi ) and centre for epidemiologic studies depression scale ( cesd ) , were also included to contrast with mmcgi .
marwit  meuser caregiver grief inventory is a predeath grief scale developed empirically from extensive qualitative interview of dementia caregivers ( marwit and meuser , 2002 ) .
its 50 items are assessed through 5point scales and summed to generate a total score and three subscale scores corresponding to the different dimensions of loss  personal sacrifice burden , heartfelt sadness and longing , and worry and felt isolation . in the original us study ( marwit and meuser , 2002 ) , mmcgi showed high internal consistency reliability , with cronbach 's alpha ranging from 0.90 to 0.96 .
it also had good construct validity , with strong correlation with anticipatory grief scale ( pearson 's correlation coefficient , r  =  0.798 ) . meanwhile ,
personal sacrifice burden subscale correlated with caregiver strain index ( r  =  0.730 ) , heartfelt sadness and longing subscale with anticipatory grief scale ( r  =  0.666 ) and worry and felt isolation subscale with wellbeing scale ( r  =  0.718 ) .
the authors of mmcgi proposed using one standard deviation above the normative mean of a population to indicate high predeath grief and a need for further interventions . in the us population
, this translates to cutoff scores of > 175 for mmcgi , > 68 for personal sacrifice burden subscale , > 59 for heartfelt sadness and longing subscale and > 52 for worry and felt isolation subscale .
such normative values were not available for the singapore population at the time of this study .
prolonged grief scale is a 12item predeath grief scale for caregivers modified from a postdeath grief scale , the inventory of complicated grief .
it is based on the diagnostic criteria of prolonged grief disorder proposed for icd11 ( prigerson et al . , 2009 ) .
its first 11 items are rated on 5point scales and summed to produce a quantifiable total score , while item 12 is scored dichotomously for the absence or presence of sociooccupational dysfunction .
it assesses the perceived burden experienced by caregivers of older persons ( zarit et al . , 1980 ) .
zbi has five domains  burden in the relationship , emotional wellbeing , social and family life , finances and loss of control over one 's life ( rankin et al . , 1994 ) .
zbi has been validated in singapore ( seng et al . , 2010 ) , with good reliability and
centre for epidemiologic studies depression scale is a 20item depression scale , assessed through 4point scales .
its four domains are depressed affect , positive affect , somatic symptoms and interpersonal problems ( radloff , 1977 ) .
cesd was previously validated in singapore ( stahl et al . , 2008 ) , with cronbach 's alpha of 0.700.79 and diagnostic performance of 6482% .
the three dementia severities in the revised third edition of diagnostic and statistical manual of mental disorders ( american psychiatric association , 1987 ) were used as a brief measure of dementia staging . from the three options ,
participants chose the description that best described the patient with dementia  still capable of independent living ( mild stage ) , needs some assistance with daily living ( moderate stage ) or needs roundtheclock supervision ( severe stage ) .
this brief measure was previously shown to have reasonable agreement with clinical dementia rating scale (   =  0.560.6 ) ( forsell et al . , 1992 ; juva et al . ,
if predeath grief exists in the asian context ( primary aim ) , it should be measurable on mmcgi with high internal consistency reliability and with convergent and discriminant validities consistent with the original caucasian constructs ( marwit and meuser , 2002 ) .
we had four hypotheses regarding convergent validity : 
 mmcgi measures the experience of predeath grief .
therefore , it should show stronger correlation with another predeath grief scale , pg12 , than with zbi or cesd.personal sacrifice burden subscale captures the experience of individual losses due to caregiving .
it resembles caregiver burden measured by zbi and should correlate stronger with zbi than with pg12 or cesd.worry and felt isolation subscale measures the feelings of losing connection with others .
it is a feature of grief reaction and should correlate stronger with pg12 than with zbi or cesd.heartfelt sadness and longing subscale resembles the traditional concepts of grief , that is , one 's intrapersonal reactions to lost relationship .
therefore , it should show stronger correlation with another predeath grief scale , pg12 , than with zbi or cesd .
it resembles caregiver burden measured by zbi and should correlate stronger with zbi than with pg12 or cesd .
it is a feature of grief reaction and should correlate stronger with pg12 than with zbi or cesd .
heartfelt sadness and longing subscale resembles the traditional concepts of grief , that is , one 's intrapersonal reactions to lost relationship .
we made two hypotheses regarding discriminant validity : 
 heartfelt sadness and longing subscale should correlate poorer with depression scale cesd , consistent with ample evidence demonstrating the difference between grief and depression ( prigerson et al .
, 2009).mmcgi should correlate poorly with finances subscale of zbi and positive affect subscale of cesd , because they are distinctly different constructs . 
 
heartfelt sadness and longing subscale should correlate poorer with depression scale cesd , consistent with ample evidence demonstrating the difference between grief and depression ( prigerson et al . , 2009 ) .
mmcgi should correlate poorly with finances subscale of zbi and positive affect subscale of cesd , because they are distinctly different constructs .
first , linear regression was performed , with mmcgi as dependent variable , to identify factors associated with predeath grief .
all variables with p    0.075 in univariate regression were entered into multivariate regression , and variables with p  >  0.05 in multivariate regression were removed through stepwise backward selections .
second , the mean scores of mmcgi and its subscales were compared with those from the original us study ( marwit and meuser , 2002 ) using onesample ttest .
we calculated the sample size using bonett and wright 's formulas ( bonett and wright , 2000 , 2015 ) , setting the 95% confidence interval width at 0.2 .
referencing to the original study ( marwit and meuser , 2002 ) , we expected the cronbach 's alpha of mmcgi to approximate 0.90 , corresponding to a minimum sample size of 11 ; spearman 's correlation coefficient between mmcgi and pg12 should approximate 0.8 , corresponding to a minimum sample size of 72 .
table  1 shows the basic demographics of the participants and the patients with dementia they cared for .
basic demographics of the caregivers and the patients with dementia they cared for ( n  =  72 ) sd , standard deviation ; mmcgi , marwit  meuser caregiver grief inventory . 

p value derived from univariate linear regression , with mmcgi score as the dependent variable .
cronbach 's alpha , which measured the internal consistency of responses , was 0.97 for mmcgi . meanwhile , the cronbach 's alpha was 0.94 for personal sacrifice burden subscale , 0.92 for heartfelt sadness and longing subscale and 0.89 for worry and felt isolation subscale . contrasting among the three scales of pg12 , zbi and cesd ( table  2 ) , mmcgi expectedly correlated stronger with pg12 ( spearman 's   =  0.79 , p  <  0.001 ) than with zbi or cesd , while personal sacrifice burden subscale correlated stronger with zbi (   =  0.74 , p  <  0.001 ) , heartfelt sadness and longing subscale with pg12 (   =  0.76 , p  <  0.001 ) and worry and felt isolation subscale with pg12 (   =  0.79 , p  <  0.001 ) .
spearman 's correlation coefficient between the mmcgi ( total and subscale scores ) and the other scales of related constructa 
  mmcgi , marwit  meuser caregiver grief inventory ; pg12 , prolonged grief scale ; zbi , zarit burden interview ; cesd , centre for epidemiologic studies depression scale . 

p  <  0.001 for all the values in the table , after bonferroni adjustment .
as hypothesized , heartfelt sadness and longing subscale correlated poorer with cesd (   =  0.58 , p  <  0.001 ) .
mmcgi also correlated poorly with finances subscale of zbi (   =  0.37 ,
p  =  0.162 ) and positive affect subscale of cesd (   =  0.33 , p  =  0.530 ) .
table  1 includes the p values derived from univariate regression analysis of factors related to mmcgi . in multivariate linear regression ( table  3 ) , factors associated with higher mmcgi score included caring for patients with severe dementia , spousal relationship , secondary or below education and malay ethnicity .
employment and primary caregiver status both had p  >  0.05 and were removed from the final model . the final model in multivariate linear regression , with mmcgi score as the dependent variable .
mmcgi scores for the respective variables were also shown mmcgi , marwit  meuser caregiver grief inventory ; sd , standard deviation ; ci , confidence interval .
table  4 compares the mmcgi total and subscale scores between the current study and the original us study ( marwit and meuser , 2002 ) .
the worry and felt isolation subscale score was 13.8% higher in this study ( p  <  0.001 ) , while the rest of the scores were comparable with those of the usa ( marginal difference of 4.4% to 3.7% ) .
comparison of mmcgi scores between the original us study ( n  =  166 ) and the current singapore study ( n  =  72 ) mmcgi , marwit  meuser caregiver grief inventory ; sd , standard deviation ; ci , confidence interval . 

prior to this study , there were uncertainties about the applicability of predeath grief concept to the asian population . in many ways ,
this study supported the existence of predeath grief in asia and attests to the universality of human emotions .
we showed that predeath grief was measurable in a reliable and valid manner , using an established predeath grief scale of mmcgi .
the risk factors of spousal caregivers and advanced dementia reported here were similarly highlighted in a systematic review of the caucasian studies ( chan et al . , 2013 ) .
even the mmcgi total and subscale scores were largely comparable with those of the usa ( marwit and meuser , 2002 ) .
these results suggest a need for clinicians to be attuned to the predeath grief experience of dementia caregivers even in the noncaucasian populations .
this is particularly important because predeath grief in dementia caregivers is commonly disenfranchised ( frank , 2007 ) , and its expression is not generally acceptable in society . unless the clinicians inquire about its presence , dementia caregivers are unlikely to volunteer such feelings and will suffer in silence until they experienced the irrevocable adverse effects of predeath grief . by such time , it may be too late to intervene .
asian caregivers showed more worries and felt isolation , and certain ethnicity experienced more predeath grief .
to attune to the predeath grief experience of caregivers , clinicians need to be mindful of the disparate presentations of predeath grief in different cultures . in the example of asian caregivers , strong expression of worries and felt isolation may be an indicator of underlying predeath grief .
such cultural sensitivity is also necessary to tailor personcentred interventions and to better support the emotional needs of caregivers in multiethnic populations .
the influence of culture on predeath grief is an area worth further exploration in future researches . the caregiver risk factors in this study ( spouse , lower education and selected ethnicity ) paralleled the predictors of complicated postdeath grief from a systematic review ( chan et al . , 2013 )
previous studies showed that greater predeath grief is a key predictor of postdeath complicated grief ( blandin and pepin , 2015 ) .
identifying shared risk factors between predeath and postdeath grief opens a window of opportunity to target efforts of case finding and early intervention in the predeath setting .
such efforts can prevent the development of complicated grief following bereavement ( schulz et al .
one of the strengths of this study lies with the location where it was conducted .
singapore is a cosmopolitan city in asia and holds a number of major asian cultures , including that of the chinese , indian , malay muslim and eurasian .
this environment provided an opportune test bed to answer our research question on the applicability of predeath grief in asia .
they alert readers on the likely presence of predeath grief even in the other parts of asia , and serve as an impetus for further researches on predeath grief in asia . in this study , limited proportion of spousal caregivers participated because a number of them could only read in chinese and not in english .
we also restricted the number of variables entering multivariate regression so that the analyses remain valid given the sample size . even with these two limitations , we have had reasonable evidence from this study to show that predeath grief do exist among dementia family caregivers in asia .
we hope to better represent spousal caregivers and identify even more risk factors in our ongoing study involving chinese mmcgi and larger sample size .
in summary , predeath grief is applicable even to the noncaucasian population , and it is detectable with an objective scale like mmcgi . clinicians working with noncaucasian populations need to be attuned to its presence and be sensitive to the influence of culture on its expression
key points 
 predeath grief is also applicable to dementia caregivers in a noncaucasian population , and it is detectable with an objective scale like mmcgi.to prevent the adverse outcomes of predeath grief , clinicians working with noncaucasian populations need to be sensitive to its presence and to the influence of culture on its expression.identifying shared risk factors between predeath and postdeath grief allows targeted efforts of case finding and early intervention in the predeath setting , thus preventing complicated grief following bereavement . 

 

predeath grief is also applicable to dementia caregivers in a noncaucasian population , and it is detectable with an objective scale like mmcgi.to prevent the adverse outcomes of predeath grief , clinicians working with noncaucasian populations need to be sensitive to its presence and to the influence of culture on its expression.identifying shared risk factors between predeath and postdeath grief allows targeted efforts of case finding and early intervention in the predeath setting , thus preventing complicated grief following bereavement . 
 
predeath grief is also applicable to dementia caregivers in a noncaucasian population , and it is detectable with an objective scale like mmcgi . to prevent the adverse outcomes of predeath grief , clinicians working with noncaucasian populations need to be sensitive to its presence and to the influence of culture on its expression . identifying shared risk factors between predeath and postdeath grief allows targeted efforts of case finding and early intervention in the predeath setting , thus preventing complicated grief following bereavement .
 objectivepredeath grief is prevalent among dementia family caregivers . when unaddressed , it produces adverse outcomes . with its research primarily conducted in caucasians , its applicability to noncaucasians is uncertain . 
 we explore the existence and the characteristics of predeath grief in a multiethnic asian population using an established predeath grief scale  marwit  meuser caregiver grief inventory ( mmcgi).methodsseventytwo dementia family caregivers were recruited from a tertiary hospital . 
 existence of predeath grief was shown by its measurability on mmcgi , together with good internal consistency reliability and construct validity . 
 characteristics of predeath grief were explored through multivariate linear regression of mmcgi and by comparing mmcgi scores with those from the original us study using onesample ttest.resultsin the asian context , predeath grief was measurable in a reliable and valid manner . 
 risk factors of predeath grief included caring for patients with severe dementia , spousal relationship and secondary or below education . 
 influence of culture was palpable  
 asians had more worries and felt isolation , and certain ethnicity showed more predeath grief.conclusionspredeath grief is applicable even to the noncaucasian population . 
 it bears much similarity to that in caucasians . yet , its expression is modified by culture . 
 clinicians working with noncaucasian populations need to be sensitive to its presence and to the influence of culture on its expression .  
 2015 the authors . 
 international journal of geriatric psychiatry published by john wiley & sons , ltd . 