Background and Objectives:Various resources exist for treating mild cognitive impairment (MCI) or dementia separately as terminal events or for focusing solely on a one-way path from MCI to dementia without taking into account heterogeneous transitions. Little is known about the trajectory of reversion from MCI to normal cognition (NC) or near-NC and patterns of post-reversion, which refers to cognitive trajectories of patients who have reversed from MCI to NC. Our objectives were to: 1) quantitatively predict bidirectional transitions of MCI (reversion and progression), 2) explore patterns of future cognitive trajectories for post-reversion, and 3) estimate the effects of demographic characteristics, apolipoprotein E (APOE), cognition, daily activity ability, depression and neuropsychiatric symptoms on transition probabilities.Methods:We constructed a retrospective cohort by reviewing patients with an MCI diagnosis at study entry and at least two follow-up visits between June 2005 and February 2021. Defining NC or near-NC and MCI as transient states and dementia as an absorbing state, we used continuous-time multi-state Markov models to estimate instantaneous transition intensity between states, transition probabilities from one state to another at any given time during follow-up, and hazard ratios of reversion-related variables.Results:Among 24,220 observations from 6,651 participants, there were 2,729 transitions to dementia and 1,785 reversions. As for post-reversion, there were 630 and 73 transitions of progression to MCI and dementia, respectively. The transition intensity of progression to MCI for post-reversion was 0.317 (2.48-fold greater than that for MCI progression or reversion). For post-reversion participants, the probability of progressing to dementia increased by 2% yearly. Participants who progressed to MCI were likely to reverse again (probability of 40% over 15 years). Age, independence level, APOE, cognition, daily activity ability, depression and neuropsychiatric symptoms were significant predictors of bidirectional transitions.Discussion:The nature of bidirectional transitions cannot be ignored in multi-dimensional MCI research. We found that post-reversion participants remained at an increased risk of progression to MCI or dementia over the longer term and experienced recurrent reversions. Our findings may serve as a valuable reference for future research and enable healthcare professionals to better develop proactive management plans and targeted interventions.