Forecasting longitudinal brain lesion evolution is critical for disease monitoring and treatment planning. Existing approaches typically learn a direct mapping from a baseline image to a future observation, without explicitly modeling the physical mechanisms underlying the lesion progression. Such an entangled modeling of structural deformation and image intensity variation limits physical plausibility, model generalization, and interpretability. To address this, we propose PDF, a Physics-grounded Disentangled Flow matching framework for longitudinal brain disease forecasting. We explicitly decompose the longitudinal modeling of lesion growth into two processes, each learned by a dedicated flow matching network: morphology evolution, which captures lesion growth and structural deformation; and intensity evolution, which models signal changes driven by variations in lesion concentration. To enforce physics-grounded constraints, we introduce a PDE-regularized loss based on lesion growth dynamics, that enforces a diffusion-reaction-advection formulation for morphological evolution. Experiments on three public longitudinal datasets spanning diverse brain diseases demonstrate state-of-the-art performance, validating the effectiveness of the disentangled modeling framework and physics-grounded learning design. Code is publicly available at https://github.com/jhuldr/PDF.
Longitudinal modelling of Alzheimer's disease progression is clinically useful only if it can describe not just the most likely next diagnosis, but how a patient may evolve over time and how reliable that forecast is. Most deep learning approaches reduce this problem to single-step classification, treating cognitively normal, mild cognitive impairment, and dementia as flat categories while providing limited insight into how uncertainty accumulates across future visits. We propose a probabilistic framework that combines ordinal diagnosis prediction, multi-horizon trajectory generation, and decomposed uncertainty estimation. A Temporal Fusion Transformer encoder is adapted with a CORAL ordinal output layer, asymmetric loss weighting, and converter oversampling to respect disease-stage ordering and improve sensitivity to MCI-to-dementia transitions. Conditioned on the learned patient-context representation, an autoregressive Mixture Density Network generates five-year probabilistic trajectories for diagnosis state, CDR Sum of Boxes, MMSE orientation, and hippocampal volume. On ADNI, the model outperforms linear, recurrent, and transformer baselines for next-visit diagnosis prediction, with the strongest gains on MCI-versus-dementia discrimination. Generated trajectories achieve near-nominal 90% credible interval coverage, widening uncertainty across the forecast horizon, and biomarker dynamics consistent with expected Alzheimer's disease progression. We further separate aleatoric from epistemic uncertainty using analytic mixture variance and a five-member bootstrap ensemble, which provides the strongest encoder diversity and output-level epistemic signal. Epistemic uncertainty is higher for rare progression archetypes, MCI and dementia patients, and under external evaluation on OASIS-3, where it increases alongside prediction error.