Objective To understand the transition of cognitive states among older adults and its influencing factors in order to provide a scientific basis for early intervention of cognitive impairment.Methods Based on ADNI data,subjects aged≥60 years and had at least one follow-up were included in this study.Cognition was divided into(normal cognition,CN),(mild cognitive impairment,MCI)and(Alzheimer's disease,AD).A multi-state Markov model was used to explore the transfer rules among the three cognitive states,and to estimate the effects of age,gender,education level,APOE4 allele and marital status.Results A total of 10073 records of 1907 subjects were included.Among them,the baseline age was 73.9±6.45 years old,and the average follow-up was 6.6 times.The intensity of transition from MCI to AD was 2.88 times of its reversal to CN(0.118 vs.0.041).For CN subjects,the probability of remaining at CN after 10 years decreased by 33.6%compared with that after the first year,while the probability of developing MCI and AD increased by 3 times and 55 times,respectively.For MCI subjects,the probability of staying at MCI after 10 years is only 0.238,while the probability of developing AD is 3.95 times that of its reversal(0.608 vs.0.154).In addition,the average residence time of CN and MCI is 18.43 years and 6.30 years,respectively.Multivariate analysis showed that male,older age,low educational level and carrying APOE4 allele increased the risk of MCI.Conclusion The cognitive function of the elderly showed a downward trend overtime.Older age,low educational level,and carrying APOE4 are risk factors for cognitive decline.