Structured choice-making procedures, referred to as preference assessments, have been frequently used to identify reinforcers for individuals with developmental disabilities; however, few studies have examined the use of preference assessments with older adults with dementia. This study evaluated the utility of 4 versions of a 2-choice preference assessment for identifying items and activities associated with high levels of engagement in clients at an adult day care program. The same 8 items were presented in 4 formats (ie, verbal, pictorial, textual, tangible), and items from each assessment were ranked with respect to the subsequent level of participant engagement with each item. Correlations were computed between the preference hierarchy and subsequent engagement levels for each format. The format with the highest correlation coefficient was subsequently used in interventions in which frequent structured choice opportunities were presented throughout the day to increase engagement. For 3 of 4 participants, the vocal modality was optimal, while the tangible modality was optimal for the fourth. Moderate to substantial increases in engagement were observed for all participants when structured choices were offered. Implications for activity engagement in adult day care programs are discussed.