Delirium is associated with loss of feedback cortical connectivity

Abstract INTRODUCTION Post‐operative delirium (POD) is associated with increased morbidity and mortality but is bereft of treatments, largely due to our limited understanding of the underlying pathophysiology. We hypothesized that delirium reflects a disturbance in cortical connectivity that leads to altered predictions of the sensory environment. METHODS High‐density electroencephalogram recordings during an oddball auditory roving paradigm were collected from 131 patients. Dynamic causal modeling (DCM) analysis facilitated inference about the neuronal connectivity and inhibition–excitation dynamics underlying auditory‐evoked responses. RESULTS Mismatch negativity amplitudes were smaller in patients with POD. DCM showed that delirium was associated with decreased left‐sided superior temporal gyrus (l‐STG) to auditory cortex feedback connectivity. Feedback connectivity also negatively correlated with delirium severity and systemic inflammation. Increased inhibition of l‐STG, with consequent decreases in feed‐forward and feed‐back connectivity, occurred for oddball tones during delirium. DISCUSSION Delirium is associated with decreased feedback cortical connectivity, possibly resulting from increased intrinsic inhibitory tone. Highlights Mismatch negativity amplitude was reduced in patients with delirium. Patients with postoperative delirium had increased feedforward connectivity before surgery. Feedback connectivity was diminished from left‐side superior temporal gyrus to left primary auditory sensory area during delirium. Feedback connectivity inversely correlated with inflammation and delirium severity.